Marketing systems: A Listen,Learn,Leverage Framework

Abstract

Macromarketing provides the conceptual ground to understand marketing dynamics in a systems setting. Social marketing offers an implementation platform through which collective behavioral change may be accomplished. Qualitative system mapping from systems thinking delivers potentially powerful tools for macromarketing and social marketing in their non-linear causality pursuits. The central theme of the paper is to unveil the marketing dynamics of a complex problem. A MAS informed social marketing systems approach is presented through an inter-disciplinary case study to address the complex challenge of increasing influenza vaccination rates in a hospital systems setting. We identify the dominant behavioral and structural dynamics blocking the desired collective behaviors which present potential opportunities to interrupt the system’s current trajectory. We capture the paradoxically contradicting group choices to systemic outcomes. We show how highly participatory understandings can act as the basis for integrated multilevel, multi-stakeholder interventions to alter the evolutionary patterns over time and space in a system. We conclude that the listening, learning and leveraging processes of undertaking qualitative marketing systems dynamics mapping for collective behavioral change are a potent way forward.

Keywords

behavior change marketing systems social marketing dynamics MAS theory

Introduction

Marketing systems thinking is central to macromarketing and addressing complex societal issues (Conejo and Wooliscroft 2015; Mittelstaedt et al. 2014; Scharmer and Kaufer 2013; Shultz, Rahtz, and Sirgy 2017). Baker et al. (2015) and Layton (2019) concur with Jagadale, Kadirov, and Chakraborty (2018, p. 95) and perceive a marketing system “as a much broader and richer concept than the neoliberal notion of ‘the market system’ which denotes a locus of economic exchanges.” Going beyond the understanding of marketing systems as large-scale markets with aggregate, population level outcomes (Fisk 1981), marketing systems incorporate complex, constantly evolving social systems and sub-systems with multi-level stakeholders in interacting communities and networks. Marketing systems are emergent, acting and reacting to changes in technology, culture, norms, customs, institutional logics and disruptions sometimes slowly, sometimes rapidly, over time. Demonstrating this more holistic view of a marketing system, Layton’s award-winning Mechanism, Action, Structure (MAS) theory concentrates on the “complex social networks of individuals and groups linked through shared participation in the creation and delivery of economic value through exchange” (Layton 2015, p. 303).

Despite the broadening of marketing systems thinking, and recent MAS developments and applications (Biroscak et al. 2014; Borden, Cohn, and Gooderham 2018; Kennedy and Parsons 2012; Truong, Saunders, and Dong 2019; Venturini 2016; Zurcher, Jensen, and Mansfield 2018), critical gaps in marketing systems thinking remain “between the description of a system and its workings and understanding the causal processes that drive system dynamics” (Layton 2016, p. 5). Furthermore, a significant implementation gap concerns the effectiveness of possible resolutions by diverting intervention efforts to the most critical points for change (Wymer 2011), as complex problems do not lend themselves to single level, once-off events, interventions or campaigns (Huff et al. 2017; Kemper and Ballantine 2017; Kennedy 2016; Truong 2017).

In response to these gaps, this paper first describes the workings of a marketing system by defining the marketing system boundaries, identifying the embeddedness of a system and contextualizing the various stakeholder action fields and localized values within the system. Second, it maps the dominant dynamics of a marketing system. Problem causality is identified and mapped through the behavioral as well as the structural dynamics operating in a focal marketing system. Finally, a Listen, Learn, Leverage (3L) implementation framework using highly participatory processes is tested to articulate the potential evolutionary shifts in a marketing system towards collective behavior change and the desired societal outcomes. The 3L framework addresses behavior changes at the macro governing level, the meso community network level and the micro individual level and so identifies multifaceted, multilevel and inherently iterative responses in relation to the dominant dynamics of a marketing system.

The research setting and case details are presented below, followed by the research methodology, including data collection and data analysis. The findings are then summarized followed by a discussion section that explains how the concepts of system boundaries, contextualization, embeddedness, stakeholder action fields and associated localized values and collective agency can describe a marketing system. Also discussed are the dominant dynamics of a marketing system to leverage its behavior and how understanding these, enriches implementation and the role for highly participatory processes. Limitations and avenues for further research are then addressed.

Literature Review

Marketing systems and Layton’s Mechanism, Action, Structure (MAS) theory

The word “system” derives from the Greek word “systema”, “syn” meaning “together” and “histanai” meaning “to set”, giving “to set together.” Systems thinking is not new to macromarketing with early researchers being both society-oriented and enlightened by systems thinking (Alderson 1964, 1965; Bagozzi 1974; Dixon 1967; Fisk 1967; Hunt 1976, 1981; Lazer 1971). However, the strength of the link between macromarketing, systems thinking and more recently, complexity science, has never been a steady trajectory (Layton and Grossbart 2006). Shaw and Jones (2005) and Vargo et al. (2017) document a decline in the interest towards marketing systems during the 1970s, driven by the increased focus on marketing management and consumer behavior. Wooliscroft and Wührer (2016, p. 14) reveal that the concept of system “showed continuing presence” in the 1980s and “regained prominence” in the early 21st century (Giesler and Fischer 2017; Humphreys 2010; Jagadale, Kadirov, and Chakraborty 2018; Layton 2007, 2008, 2011, 2015; Layton and Grossbart 2006; Peterson 2013; Vargo et al. 2017; Wooliscroft and Ganglmair-Wooliscroft 2018).

Layton (2007 p. 230) defines a marketing system as that of:

“a network of individuals, groups, and/or entities linked directly or indirectly through sequential or shared participation in economic exchange that creates, assembles, transforms, and makes available assortments of products, both tangible and intangible, provided in response to customer demand.”

By addressing key constructs of a marketing system, the social mechanisms (M), stakeholder action fields (A) and structure (S), Layton accentuates the centrality of systems thinking in a marketing setting to understand the underlying causal dynamics. Importantly, MAS recognizes that the stakes of stakeholders change over time; stakes alter depending on the strategic issue in hand; stakes evolve as the mix of stakeholders in the system changes and stakes affect the macro, meso and micro levels of a marketing system.

The system boundary is permeable to inputs from, and outputs to, the environment (Bossel 1999). The boundary delineates a marketing system, which is a network of stakeholders, connected in a structure (provisioning platforms, governance, rules) and engaged in social mechanisms (value-based exchanges, relationships, trust, conflict, communication), which allows for the performance of specific stakeholder functions (delivery, product and services development, pricing, partnerships) in an environment (choice context) outside the system boundary.

Consistent with Peterson’s (2013) call for a societal stakeholder mindset, any marketing system description regardless of scale and boundaries, requires an understanding of the range of system stakeholders, all of whom have different lives, views, experiences, expectations, needs and behaviors. To explain the dynamics of stakeholders and their stakes, Layton (2015) makes use of analytical sociology to categorize stakeholders as incumbents, challengers or regulating/governing agencies. Incumbents consist of the system’s dominant stakeholders interested in preserving the status quo. Challengers are the stakeholders who seek to initiate change by challenging the status quo. Regulating/governing agencies are system operators responsible for its governance and smooth running. The individual incumbent, challenger and regulating/governing stakeholders in a marketing system form various strategic action fields (SAFs) based on their shared agendas, group interactions, social mechanisms, localized blends of self-interest, mutuality and morality values and different choices. MAS theory argues that only through understanding the interactions between incumbent, challenger and regulating stakeholders and associated stakeholder action fields in a marketing system, is it possible “to provide the foundations for policy prescription” (Layton and Duffy 2018, p. 1).

Empirically, Duffy (2016) pioneered the first exploration of MAS concepts through a case study about the whale shark marketing system of Ningaloo in Western Australia. A year later, Duffy, Northey, and van Esch (2017) successfully applied social mechanism theory within MAS, to understand the social upheaval caused by the financial system collapse in Iceland, while Kennedy et al. (2017) examined the issues, actors and social mechanisms involved in perpetuating fast fashion. Jagadale, Kadirov, and Chakraborty (2018) extended MAS by studying the social mechanism of dignification and dignity symbolism. Wooliscroft and Ganglmair-Wooliscroft (2018) used MAS to analyze marketing systems for negative externalities, societal contributions, growth scenarios and developmental opportunities. All of these applied studies investigated how “many stakeholders perpetuate the problem, with multiple levels of interconnecting factors involved” (Kennedy 2016, p. 355).

As pioneering applications of MAS theory, they confirm the strong explanatory power of social mechanisms, strategic action fields and structures in a marketing systems setting. They indicate the combined MAS-based constructs have the potential to explain complex problems. Critically, they empirically confirm it is an understanding of the behavioral dynamics in a marketing system, and not just the structural dynamics, that matter. They highlight that for marketing systems, MAS theory represents a fundamental development as the “dynamics have become significantly more important than structure as providing the essential drivers of change” (Batty 2007, p. 65). However, there are no suggestions as to how the agency of incumbents, challengers, regulating/governing stakeholders explain the diversity of SAFs and their collective behaviors; nor how to map and explain the interrelationships and interdependences of SAFs and associated localized value-based exchanges in a marketing system and how to leverage MAS constructs for systems change or transformation (Senge 1990).

Social Marketing and Systems Change for Complex Societal Problems

Social marketing “critically examines commercial marketing so as to learn from its successes and curb its excesses” (Hastings and Domegan 2018, p.5). Social marketing like macromarketing concerns itself with social problems and the consequences of marketing systems, quality of life, sustainability and excess consumption issues. In its earliest manifestation and now, social marketing is used to focus on modifying, adapting or changing the behavior of a target audience at the micro level. A wave of developments shows social marketing also delivering behavior change at the community or at the policy level. The latest social marketing expressions seek coordinated collective behavior change across micro, meso and macro levels. This emerging collective behavior change orientation encompasses macro-social marketing (Kennedy 2016, 2017; Kennedy, Kemper, and Parsons 2018; Kennedy and Parsons 2012), community-based prevention marketing (Bryant et al. 2014), community-based social marketing framework (Biroscak et al. 2014, 2019), adapted Behavioral Ecological Model (Brennan, Previte, and Fry 2016), strategic social marketing (French and Gordon 2015), and systems social marketing (Domegan et al. 2016).

The inter-construct relationships of social marketing in a systems context center on a multi-level and multi-stakeholder implementation remit for behavioral change. Of particular interest are the barriers that block or hinder behavioral change in a social problem setting (McKenzie-Mohr and Schultz 2014). This implementation perspective avoids a victim blaming linear, dyadic exchange unit of analysis. Though the various social theories used to endow social marketing with its implementation strengths vary substantially, in all developments, social marketing demonstrates an appreciation for the localized context and the social determinants of behavior, together with its potential for applied marketing systems thinking.

Social marketing has always been strong in the design and development of single level interventions, campaigns and strategies, namely problem articulation for improved and/or positive societal outcomes via formative research and intervention design and evaluation (Tapp 2018). Social marketing now requires the use of participatory and collaborative technologies to attract stakeholder and SAF participation, partnership insight and the co-creation of exchange propositions that deliver social and individual benefits. The role of social marketing is one of building top-down and bottom-up partnerships, developing cross-functional teams with “new modes of communication, adopting alternative conversation roles and styles to facilitate interaction or creating opportunities for knowledge sharing, learning and dialogue” (Luca, Hibbert, and McDonald 2015, p. 202).

MAS theory integrates well with social marketing and its drive to change behaviors that benefit individuals and communities for the greater good. MAS theory helps social marketing to plan and execute large scale behavior change interventions by targeting the social mechanisms, the structure and the stakeholder action fields and their interactions in a focal marketing system. The crux lies in understanding how the behavior and exchange dynamics affect the different stakeholder groups and structures in the system. MAS hypothesizes that some stakeholder action fields will act, react and respond positively to the marketing system dynamics engaging in value-based exchanges. Others may respond in a negative manner, resulting in the lack of exchanges. This dynamical understanding of the marketing exchange system is crucial for social marketing, which seeks ways to progress large-scale, multi-level change (Brennan, Previte, and Fry 2016; Kennedy 2017).

Systems Thinking and System Mapping for Social Marketing

Systems theory is a broad area of research and there are different perspectives on systems within the marketing discipline (Löbler 2016). For instance, system dynamics addresses a broad range of problems by formulating dynamic hypotheses as well as testing computer-based simulation models (Sterman 2000; Torres 2019). This is predominantly a quantitative approach. Some system scientists advocate the complementary application of qualitative and “softer” approaches to the analysis of systems, stressing their significance in issue structuring and problem solving (Coyle 1996; Kunc 2012; Kunc and Morecroft 2007; Wolstenholme 1999). The importance of hard-to-quantify variables is mentioned by Sterman (2018, p. 23) in his seminal publication dedicated to the 60th anniversary of system dynamics and its founding father Jay Forrester:

“Forrester argued early and correctly that data are not only numerical data and that “soft” (unquantified) variables should be included in our models…. Jay noted that the quantified data are a tiny fraction of the relevant data needed to develop a model and stressed the importance of written material and especially the “mental data base” consisting of the mental models, beliefs, perceptions and attitudes of the actors in the system.…Omitting important processes because we lack numerical data to quantify them leads to narrow model boundaries and biased results…”

Social marketing systems literature agrees with this, especially for complex social problems and contexts affected by numerous variables which are hard to quantify (Biroscak et al. 2019; Pettigrew and Roberts 2011). To capture the “mental data bases” (Sterman 2018), a participatory approach to mapping system causality, also known as group model building, is key. Group model building (GMB) is a family of collective decision making methods within system dynamics (Bérard 2010; Ricigliano 2016; Torres 2019). GMB involves system stakeholders in the origination of shared mental models of the problems and consensual unravelling of the underlying causes of these problems to support strategic decision-making (Akkermans and Vennix 1997). Importantly, GMB provides deep insights into system behavior via feedback loops.

Table 1 summarizes the inter-construct relationships from MAS and social marketing theories, incorporating feedback mechanisms and group model building. For implementation, the social marketing planning process (Hastings and Domegan 2018) is used to anchor MAS theory and feedback loop mapping in a proposed Listen, Learn, Leverage framework.

Table 1.

A Listen, Learn, Leverage Framework.

Phases	Steps
1. Listen to the focal marketing system; Problem Definition	Systems context and boundary analysis Barrier and MAS analysis Stakeholder action fields and exchange mapping
2. Learn about the marketing system dynamics; Group Model Building	Qualitative MAS barrier structuring Identification of individual causal loops & narratives Qualitative marketing systems map Identification of dominant feedback loops Validating the map
3. Leverage change in the marketing system; MAS strategy for shifting the system towards social good/societal outcomes sought	Identification of leverage points Stakeholder action fields, social mechanisms and structure options Multilevel, multifaceted MAS strategy Implementation Evaluation

Adapted from Hastings and Domegan 2018.

Research Context: Low Influenza Vaccination Rates

Hospitals provide the context for this research. Social scientists view hospitals as highly complex systems involving large heterogeneous groups of interdependent stakeholders (e.g. doctors, consultants, nurses, patients, management, administrators and cleaning and catering staff) with different values and engaged in dealing with human problems (Georgopoulos and Matejko 1967). In a similar vein, Leveson et al. (2016, p. 1) argue that:

‘All medicine is practiced within a system. A hospital is a dynamic and complex system, interacting as a structured functional unit to achieve its goals (e.g., treating patients). One system may be nested within another; for example, a hospital is nested within a larger health care system, and an intensive care unit exists inside a hospital. The behavior of a system reflects the linkages and interactions among the components or entities that make up the entire system. The behavior of the components or entities that exist within that system is influenced by the system design and structure.’

Annual influenza vaccination, whether to have the influenza vaccination or not, is a choice for healthcare workers in this highly complex medical, therapeutic, managerial, social and logistical system (World Health Organization 2019a, 2019b). Compared to adults working in non-hospital settings, healthcare workers are at significantly higher risk of influenza (Kuster et al. 2011). Achieving a higher uptake of influenza vaccination among healthcare workers in the hospital system is recognized as a vital infection control intervention and occupational health issue to reduce the risk of influenza transmission between patients and healthcare workers (Harkin 2018). The term “occupational health” refers to promoting the optimum health of workers and protecting them from possible ill effects of work-related activities in their place of work. WHO “considers health workers to be a priority target group for seasonal influenza vaccination” (World Health Organization 2019b, p. 1).

Supporting WHO’s recommendations, the WHO Regional Office for Europe presents a new approach, tailoring immunization programs for seasonal influenza (TIP FLU) (WHO Regional Office for Europe 2015). Focusing on the detailed complexity of influenza vaccinations in the context of hospital systems, it advocates sophisticated yet conventional dyadic based behavior change and health program planning models. Despite WHO’s recommendations and TIP FLU guidelines, influenza vaccination uptake remains low among healthcare workers. Influenza outbreaks in healthcare settings continue to occur annually in most European countries, including Ireland (Dini et al. 2018; European Centre for Disease Prevention and Control 2017).

In the Irish hospital system, the focus and context is the Saolta University Health Care Group consisting of six hospitals of varying sizes, structures and stakeholders in the West of Ireland where the influenza vaccination rate among healthcare workers accounts for an average of 15%, significantly below the national influenza vaccination target of 40% recommended by the Health Service Executive of Ireland, as highlighted in Table 2 (HSE-Health Protection Surveillance Centre 2016; Quintyne et al. 2018).

Table 2.

Seasonal Influenza Vaccine Uptake among Healthcare Workers by Individual Hospital, 2015-2016.

Hospital	Total eligible staff	Total staff vaccinated	Total staff vaccinated (%)
Mayo General Hospital, Castlebar	1142	154	13.5
Portiuncula Hospital, Ballinasloe	771	167	21.7
Galway University Hospitals (University Hospital Galway & Merlin Park University Hospital)	3,594	501	13.9
Roscommon County Hospital	309	35	11.3
Sligo General Hospital	1,698	304	17.9
Letterkenny University Hospital	1,641	238	14.5
TOTAL SAOLTA*	9,155	1,399	≈15 (mean value)

Source: HSE-Health Protection Surveillance Centre (2016).

* Saolta University Health Care Group stands for a hospital group, serving the population of Ireland’s western and north-western counties of Galway, Donegal, Leitrim, Sligo, Mayo, Roscommon and adjoining areas.

Within the Saolta University Health Care Group system, as is the case in most countries and hospital systems, annual influenza vaccinations are not mandatory. All healthcare workers have a choice each year as to whether they engage with the voluntary annual influenza vaccine exchange, or not. This has resulted in persistently low annual influenza vacation rates among nurses, the largest healthcare stakeholder category within the Saolta University Health Care Group.

Research Methodology

The research question asked “What combination of theoretical and methodological inter-construct relationships from macromarketing, social marketing and systems thinking, can help in capturing and leveraging the dynamic causality of a focal marketing system?” The research methodology followed the augmented social marketing strategic planning process outlined in Table 1, consisting of three phases. Phase l listened to the marketing system problem of persistently low influenza vaccination rates among nurse healthcare workers via formative research. Phase 2 learnt of the dynamics of the marketing system through explanatory research using group model building and feedback loops, and Phase 3 designed a social marketing MAS strategy to leverage the dynamics of the system for change.

Phase 1 began with the determination of the boundaries of the marketing system in relation to the social problem, issue or challenge and the system/problem embeddedness. A conventional literature review identified documented barriers to influenza vaccination in other hospital and community contexts. These were classified using social mechanism, structure and stakeholders definitions (Layton 2015). The next step involved a systems stakeholder analysis based on their roles as incumbents, challengers or regulating agents (Layton 2015). Primary formative research followed, using a purposeful sample of nursing healthcare workers (n = 137) including dissenting voices to identify and list the top three barriers to the voluntary uptake of the influenza vaccination in the Saolta University Health Care Group.

In-depth interviews (n = 8) also occurred with incumbent, challenger and regulating system stakeholders during Phase 1 e.g. trade union, nursing directors, senior hospital management, and doctors. A stakeholder action field analysis was completed with direct structured observation (n = 8) of the stakeholder action field influenza vaccination exchanges, or not, and associated MAS social mechanisms. This research generated 368 individual MAS barriers to influenza vaccination. Basic stakeholder action fields’ exchange mapping was implemented to identify nursing healthcare networks with respect to influenza vaccination uptake (Figures 2 and 3).

Figure 1.

A social marketing qualitative systems map of the low flu vaccination factors among nursing healthcare stakeholder action fields.

Figure 2.

Value exchange mapping for “Get influenza vaccination” and “Willing to get influenza vaccination” nursing healthcare stakeholder action fields.

Figure 3.

Value exchange mapping for “Never had influenza vaccination” nursing healthcare stakeholder action field.

During the second phase, the dynamic relationships between all the MAS barriers identified in Phase 1 were identified using group model building and causal loop mapping by the core modelling group (Ricigliano 2016; Sterman 2000; Warfield and Cárdenas 2002). The core modelling group consisted of four experts in the influenza vaccination system and three social marketers with system mapping experience. The tasks in phase two were to:-

analyze MAS system-affecting barriers and group them into barrier themes/categories, categorized as behavioral barriers (social mechanisms and stakeholders) or system structure barriers.

tell the stories i.e., narratives of these barriers themes via individual feedback loops;

connect individual feedback loops into a qualitative marketing systems map; and

identify the dominant dynamics that explain the stakeholder action fields and their influenza vaccination behaviors.

This resulted in a marketing systems map, depicting 14 underlying causal loops of MAS barriers that inhibited influenza vaccination uptake for nursing healthcare workers in the Saolta hospital system (Figure 1 below). The map was originated with the help of Kumu software, a visualization platform for mapping systems and causal relationships (Mohr and Mohr 2011). This software does not strictly adhere to the traditional design of causal loop diagrams applicable in system dynamics. It allows the simultaneous use of “+” and “-” polarity signs on the same causality-marking arrow. For instance, two “+” signs on a single arrow means a causal link between two variables, where a change occurs in the same direction. When different polarity signs are used on a single arrow, it means opposite direction of causality.

In Phase 3, using the qualitative marketing system MAS map, leverage point identification, discussion, and substantiation involved lengthy collective consultation procedures, undertaken among the core modelling group, the three stakeholder action fields and individual system stakeholders. System leverage consultations took into consideration impact strength, feasibility in relation to available tangible and intangible resources and the existing level of penetration of suggested leverage decisions (McKenzie-Mohr and Schultz 2014). Leverage points that combined larger impact, a higher probability for realization and lower penetration levels at present were prioritized. The discussion of “what if” scenarios, as well as long- and short-term implementation strategies, was part of the consultation process.

Findings

The influenza vaccine rate for nursing healthcare workers in Saolta hospital system rose from 8.8% in 2015/2016 to 16.8% in 2016/2017 to 29.3% in 2017/2018 and 36.1% in 2018/2019. The figures for influenza vaccination uptake among all healthcare workers in Saolta hospital system rose from 15% to 25%, 37% and 39.2% in 2015/2016, 2016/2017, 2017/2018 and 2018/2019 influenza seasons, respectively.

A marketing interpretation of the system map depicts 14 underlying causal loops of MAS-based barriers that inhibit influenza vaccination uptake for nursing healthcare workers in the Saolta hospital system. The ‘Fit and Healthy Beliefs’ of nursing healthcare workers show they believe that they are invulnerable to influenza and its side-effects. Five other feedback loops are connected to the “Fit and Healthy Beliefs” nursing healthcare workers have regarding influenza and influenza vaccination. These include “Vaccine ineffectiveness”: Beliefs in low vulnerability to influenza and its effects causes nurses to question the effectiveness of the vaccine. “Lack of Peer Vaccination”: If nursing healthcare workers don’t believe they need the influenza vaccine, they are less likely to get the vaccination and uptake will be low. If uptake remains low, flexible access to vaccination through peer vaccinators may be impacted. “Harming Immune System”: Nurses believe they are fit and healthy, that they can fight any infection themselves, and that a vaccination can harm your immune system. “Apathy”: Nurses believe they are not vulnerable to influenza, and even in the event that they do get influenza, play down the seriousness of having influenza, influencing their apathetic attitude of “what will be, will be.” The final loop is “Vaccine Not Needed”: Nurses believe in their own healthy immune system which heightens perceptions that the vaccine is not needed.

“Past Experiences” increases people’s fear of being unwell after the influenza vaccination. Directly interacting with “Past Experiences” are six other loops, including:- “Fear of Side-effects”: Increased awareness of the risks of side-effects and fear of getting sick after the vaccine are influenced by anecdotal past experiences. Media coverage can lead nurses to fear that future evidence may show that vaccines can do more harm than good. “Evidence”: Nurses’ perceived fears of inadequate research into influenza vaccines coupled with their perceived fears that vaccines are produced hastily without proper adequate safety testing heightens the mistrust in big pharma and Government. This leads to the belief that in future evidence could contradict existing evidence, leading nurses to take the view point that it is overall safer not to avail of the vaccine. “Fear”: Mistrust feeds into part of the general fear in the population about vaccinations, their components and side-effects. This heightens the perceptions of vaccine risks. Nursing healthcare workers believe getting the vaccine is not worth the risk and this negatively impacts vaccination uptake. “Access”: If vaccination uptake is reduced, this will negatively impact occupational health clinic flexibility and therefore impact vaccination access. “Communication”: A lack of motivation or interest in vaccination will lead to ineffective communication of the facts surrounding vaccination and “Misconceptions” of influenza, its vaccines and their effects is fueled by ineffective communications and shapes perceptions of past experiences.

Arising from phase 3, 130 tactical, ad hoc activities or individual ideas and six strategic system leverage points for iterative influenza intervention strategies for nursing healthcare workers were identified. Ad hoc ideas included, for example, “Notices need to be on doors where you come and go to work, e.g. ward doors, revolving doors. Quick and easy to pick up a small sheet” (Nurse K). Other individual suggestions identified incentives and extended delivery hours as a way forward e.g. “if someone (a peer vaccinator) offers it to me, great to be handed a coffee while waiting” (Nurse A). “If peer vaccinators come around a few times including night shifts – this would be fantastic” (Nurse F). The marketing system leverage points responding to the 14 underlying causal loops included:- (1) multilevel, multi stakeholder peer vaccination, (2) influenza champions, (3) mutuality based exchanges, (4) ward/unit delivery, (5) influenza literacy and (6) individualized hospital communications incorporating influenza, not flu, narratives.

Discussion

Describing a Marketing System

Systems, system boundaries, contextualization and embeddedness

Identifying the desired yet-to-be achieved social and/or societal outcomes as a marketing systems problem facilitates macromarketers to stand outside the system, to identify the context of the system, and to determine the appropriate marketing system boundaries and embeddedness. Defining the desired outcome as a collective behavioral problem, e.g. persistent low influenza vaccination rates among healthcare workers, produces system boundaries e.g. the hospital influenza vaccination system. It highlights that marketing systems are embedded; the influenza vaccination hospital system is embedded in a higher level influenza vaccination system that includes the adjacent and complimentary community healthcare systems such as nursing homes. Both systems exist and operate for similar purposes, but with sufficiently unique and different cultures, norms, structures, policies, practices, stakeholder action groups, communication flows and delivery mechanisms to warrant separate system boundaries. This is most evident in the governance structures of the influenza vaccination sub-systems. For example, the hospital system mandates influenza vaccinations are provided to the population of healthcare workers by trained nurses while the community system dictates doctors administer influenza vaccinations to the healthcare worker population.

Furthermore, the hospital and community influenza vaccination systems are embedded within the national vaccination system that subsumes, for example, measles, mumps, rubella and cervical cancer vaccinations. In turn, this larger scale vaccination system is nested within the supervening national healthcare system situated within the European and WHO healthcare systems. Such embeddedness and hierarchical relations within the system and its sub-systems increases the dynamic complexities of the behavioral interactions and structures, which is evidenced in the findings. Moreover, it is the evolutionary processes that point to the “scaled” nature of systems. Marketing systems can be localized sub-systems, adjacent, complimentary, competitive and/or supervening systems and are nested within one another (Baker et al. 2015; Duffy 2016; Duffy, van Esch, and Yousef 2020; Kennedy 2017; Layton 2015).

Marketing systems can be described as embedded relative to each other. They can also be described as embedded adjacent, complementary, competing and supervening systems relative to other provisioning and exchange systems e.g. prescriptive, collaborative, illegal and informal exchange systems. Describing the embeddedness of a marketing system is critical to identifying and understanding the boundaries and workings of a focal system and movement towards the desired societal outcomes.

The context, degree and scale of embeddedness facilitates the selection of a focal marketing system and the delineation of its boundaries as the unit of analysis. It allows the complexity of the system to be as simple as necessary, but not simpler. Choosing and describing a focal marketing system in this manner facilitates a meso view of a system through which macro and micro behavior dynamics and structural dynamics can be identified, analyzed and mapped. The importance of this view is highlighted both in social marketing (Biroscak et al. 2014; Bryant et al. 2014; Domegan et al. 2017; McHugh et al. 2017) and macromarketing (Duffy 2016; Duffy, van Esch, and Yousef 2020). Furthermore, the meso and community-based influences have been confirmed for specific contexts of epidemiologic risks and occupational health hazards (Spencer et al. 2020).

Seeing the problem in terms of its whole, its elements, levels and their interrelationships, taking the many interactions and multi-level stakeholders into account to explain the voluntary exchanges or not, enables one to understand its outcomes. The findings, describing the workings of the focal marketing system, show the stakeholder action fields’ dynamics are nested within the wider vaccination system and its workings. This is most evident in the “Past Experiences” dominant loop and associated “Fear of Side-effects”, “Fear” and “Evidence” loops where consistent references to the complementary national vaccination system are made. Here, anti-vaccination overtones are present.

It is difficult to understand system causality if the embeddedness of the system with its actions and reactions is overlooked. Even when the embeddedness of a marketing system is considered, system boundary demarcation is still an arbitrary process (Kleidon 2016). It is important to adopt an approach that is as inclusive as possible (Bryson 2004). Such arbitrariness specifically includes “the micro (individuals), meso (e.g. community, workplace, service and social capital) and macro (e.g. policy, structures, power relations and markets) levels” of a marketing system (Gordon et al. 2018, p. 101). In this study, micro level stakeholders were the nurses, doctors, patients, family members; meso level stakeholders included ward nurse managers and consultant groups such as cardiovascular and renal teams, while the macro level stakeholders extended to the Directors of Nursing, the Board of Management and the trade unions.

Stakeholder action fields, localized values and collective agency

Layton (2019) posits that exchange is always about a localized blend of self-interest, mutuality and morality values within and between stakeholder action fields in a marketing system. These localized exchanges create or destroy value. Can a marketing systems map capture the localized exchange contradictions between the stakeholder action fields? Can a marketing systems map explain the multi-level exchanges that occur and do not occur? Our findings suggest yes. When a qualitative marketing system map (Figure 1) is augmented with even simplistic stakeholder action field value-based exchange mapping (Figures 2 and 3), the seamless webs of stakeholder action fields with their own agendas, communication and self-organization processes exhibiting different collective agency begin to come into focus.

Jordan (2019) suggests there will be a minimum of three generic stakeholder action fields in a marketing system. There are “doers”, those who engage in the desired behaviors and exchange, e.g. nursing healthcare stakeholder action field who get the annual influenza vaccination. There are those who are “willing”, those who plan to engage and avail of the exchange offerings, e.g. nursing healthcare stakeholder action field who plan to get the annual influenza vaccination (see Figure 2). Finally, there are “non-willing”, those who avoid the desired behaviors and choose not to avail of exchanges, e.g. the nursing healthcare stakeholder action field who repeatedly refuse the annual influenza vaccination (see Figure 3).

Each of these stakeholder action fields display different social mechanisms at work, that is, altered communication, cooperation, trust and self-organizing patterns of behaviors in relation to the dynamics. As a consequence, the SAFs also highlight dissimilar dispositions towards potential interventions, co-evolving capacities and pathways. The “Fit and Healthy” beliefs and “Past Experiences” of one stakeholder action field, nursing healthcare workers who do not get the influenza vaccine, predisposed them to believe that they were invulnerable to influenza or its side-effects. This stakeholder action field engaged in less communication, interactions, co-operation and trust with other stakeholder action fields about getting influenza vaccinations. Rather, their communication, interactions, co-operation, trust and self-organizing mechanisms were used to avoid influenza vaccinations. They perceived the existing localized value blend to be dominated by the morality values of the system and governing stakeholders, i.e., nursing healthcare workers “should” get the influenza vaccination. The governing stakeholders, the Board of Management and Director of Nursing, were perceived to be adopting a domination and/or authoritarian power over this stakeholder action field. In turn, this had a disorganizing effect on the relationships between stakeholder action field and other stakeholder action fields in the system. Their collective behavior and social mechanisms were negatively orientated towards the desired system outcome.

The stakeholder action field who believed the influenza vaccine was beneficial for their health and wellbeing and had the influenza vaccine, engaged in more positive communication, interactions, co-operation, trust and self-organizing social mechanisms in relation to the influenza vaccine with others in their stakeholder action field. Their stakeholder action field accepted the governing stakeholders’ self-organizing power and collaborated with the governing stakeholders. Importantly, this stakeholder action field also used various social mechanisms to engage with other stakeholder action fields in the hospital system, in complimentary systems (e.g. community influenza system) and in supervening systems (e.g. the national health system and WHO influenza system). From this perspective and for this stakeholder action field, one of the consequences of democratizing influenza vaccinations was to achieve greater degrees of self-organization.

Both stakeholder fields show “the human ability not just to act but to act in concert” (Arendt 1986, p.64). We concur with Layton (2015), Duffy, van Esch, and Yousef (2020) and Byrne and Callaghan (2014) that stakeholder action fields self-organize through the various social mechanisms in the system to engage or not engage with the desired collective outcomes. In essence, each stakeholder action field is a contextualized network of actions and reactions with its own collective agency. Bagozzi (1975, p.5) succinctly summarizes this by stating that “Man not only reacts to events or the actions of others but he self-generates his own acts.” Describing the localized blend of value-based exchanges occurring or not occurring within stakeholder action fields in a focal marketing system enables macromarketing to widen and deepen its understandings of the everyday life choices and collective outcomes at all levels.

The Dominant Dynamics of a Marketing System

Identifying the dominant dynamics of the marketing system is a good starting point to understanding the behavioral and structural causal processes at work. Importantly for marketing systems based on mutual choices and benefits, more complex marketing models do not necessarily provide much additional gain. According to Barry Richmond and Steve Peterson (Peterson 2004, p. 3),

“There is significant value to be gained at relatively low cost from the application of basic system dynamics skills. Once you move past simpler applications, diminishing returns can quickly set in. As the complexity of the model increases, the amount of effort, skill, and time required to underwrite that complexity increases disproportionately relative to the amount of value derived.”

Furthermore, identifying the dominant dynamics can provide clarity around what to change, not to change and how that change generates alignment between the stakeholders in the system, synthesizing the diversity of individual expert and stakeholder action fields’ points of view. It allows for constant, adaptive system-improving outcomes refinement, assisted by collective visualizations of mental models of the system, rather than outputs. Outputs are often one-dimensional, dyadic exchanges and short-lived. One can ask how the dominant dynamics and/or other dynamics shape delivery, technology, governance, communication, co-operation mechanisms to describe the marketing problem more fully and to co-create resolutions in iterative steps that requires localized stakeholder action field decisions, and reflective practice.

Each of the 14 causal loops in the findings and Figure 1 represent behavioral and/or structural dynamics at work in the focal marketing system. Of the 14 loops, the “Fit and Healthy Beliefs” and “Past Experiences” loops are the dominant dynamics of the influenza vaccination system. They are dominant as they are connected to and drive the other dynamics in the marketing system. They explain the differences between the various stakeholder action fields, structural and behavioral anomalies and ultimately, why the system has not achieved the desired collective outcome. They also explain some of the successes seen in other adjacent influenza systems, e.g. hospital systems in the east of the country where the influenza vaccine is generally perceived as the ultimate immune boost.

For example, concentrating on the dominant dynamics, the introduction of peer vaccination becomes a critical leverage point for change in the system. This intervention presents the potential to affect the “Fit and Healthy Beliefs” and “Past Experiences” among all three stakeholder action fields to generate an increase in influenza vaccination rates within each stakeholder action field. Peer vaccination creates a new service, a new localized blend of values that can directly access the three distinctive stakeholder action fields in different ways. Peer vaccinators can deliver pre-contemplation stages of change activities to interrupt and counteract or detrimental social mechanisms such as fear and apathy for the “non-willing” group (“Never had influenza vaccination”), while supporting “doers” (“Get influenza vaccination”) with maintenance stage of change tools. Peer vaccination, manifesting localized value-based exchanges in different contexts, e.g. staff not losing days to sick leave, protecting older or younger vulnerable family members, protecting patients, being part of team or unit and being a visible active leader, can significantly connect the different stakeholder action fields and their choices to collective hospital outcomes.

Looking forward, to paraphrase Churchill (Langworth 2008), “we shape our systems, and afterwards our systems shape us.” If we can harness the energy of the dominant behavioral dynamics, we can potentially bring about greater and more sustained change in the system towards the desired collective outcomes. We can integrate scaled responses and interruptions using the dominant dynamics (and dynamics) of the marketing system, where possible, to provide behavioral and/or structural implementation support with localized decision-making and mutual choices. We can deepen our understanding of the social mechanisms that potentially could contribute to system change, disruption, success and/or failure. We can move into the narrow corridor, into that system space that balances the powers to dominate and powers to collaborate between the governance/regulating stakeholders, incumbents and challengers (Acemoglu and Robinson 2019; Arendt 1986; Parsons 1963) and between the doers, willing and non-willing stakeholder action fields. That is, the emergent power flows between top-down and bottom-up stakeholders and across the stakeholder action fields in the marketing system.

For influenza vaccinations, the three existing stakeholder action fields could, over time, merge to generate a new stakeholder action field. The “ward/unit” could become the context and loci for influenza vaccinations. A ward/unit stakeholder action field refers to the nursing healthcare workers interactions contextualized as part of doctors, colleagues, patients, family and other healthcare workers relationships and interactions. It represents a shift away from the perceived and current “nurses only”, professional, actor network approach to dealing with “nurses in the context” of their ward or unit i.e., a social network approach with a particular focus on the networks of social relationships in a social system and their agency (Byrne and Callaghan 2014). It could potentially alter both the behavioral and structural dynamics of the existing stakeholder action fields, disrupt the negative status quo and create new positive social team/peer dynamics. How so? Consistent with Byrne and Callaghan (2014, p.126), “understanding these relationships as complex, based in non-equilibric systems that are emergent and continually reproducing, but also as changing, seems to be the foundation of an approach that we would want to deploy.” A ward/unit stakeholder action field generates opportunities for new healthier emergent power structures to emerge as the power exercised by different stakeholder action fields to collaborate with one another is a self-organizing process across scale.

For these reasons, a ward/unit stakeholder action field could, according to nurses and doctors, cultivate a more co-operative and collaborative working environment, supportive of annual influenza vaccinations. Organizing influenza vaccinations in ward or unit context would add to a nurses’ sense of responsibility and accountability. It could be a cross-professional platform rather than a hospital-wide structure where it can be easier to avoid the accountability of not availing of the vaccine. This would be particularly important to the “non-willing” stakeholder action field (“Never had influenza vaccination”), many of who reported feeling alienated from the management and other hospital groups. In keeping with Layton’s 2019 thinking, a ward/unit stakeholder action field may invoke more empowered self-organization, e.g. ward competitions for the best influenza vaccination rates, and blur the boundaries between “doers” and “non-willing” in the hospital. This allows for the evolution of more relational exchange structures suited to a marketing system rather than the traditional hierarchical top-down hospital structure of centralized public health provisioning platforms.

Implementation – an Enriched Framework

Synthesizing all of the suggested resolutions, activities and options, around the dominant dynamics and associated behavioral and structural dynamics has significance because they are a way of dealing with the relational aspects of a marketing system. This creates more integrated iterative responses that are multi-level, multi-stakeholder in nature, and more likely to engage all stakeholder action fields. For example, the introduction of peer vaccinators cannot be treated as an event, it is an ongoing development within the system requiring support, resources and implementation to be successful. Peer Vaccinators represent a positive opportunity for a permanent assets-based interruption to the adverse trajectory of the evolutionary processes in the system. They can leverage the different embedded mechanisms, relationships and interactions for the various stakeholder action fields to support improvements in the system. Influenza champions can also leverage the behavioral and structural dynamics in a similar manner. Knowing outcomes will be emergent, continual adaptations will be required of whatever leverages are used.

The involvement of various and sometimes conflicting stakeholder action fields in the consensus-based elicitation of the possible resolutions, interruptions and leverage points, together with their co-created top-down and bottom-up buy in to a new-shared future, lies at the core of the marketing systems desired outcomes. When the majority or all stakeholders and stakeholder action fields are involved in the mapping and design processes, this engages in the co-evolution and co-production of outcomes, which employ crucial kinds of lived expertise. Results become more relevant and practical and increase the probabilities of the system disruptions being successful.

Had the ad hoc activities and events recommended by expert stakeholders in the system been implemented, such as the conventional health promotion SPLAT suggestions, i.e., some posters, leaflets, ads and things (Tapp 2018), the result would have been a unidimensional campaign. Instead, the enriched 3L framework provides a more contextualized, more nuanced and multilevel response than a non-marketing system intervention which would most likely have concentrated on the top barriers perceived to be important i.e., the lack of access, the lack of communication and insufficient influenza knowledge. A non-system approach would have targeted a designed population (nursing healthcare workers) in a siloed or isolated manner, not in a self-organizing networked mode. The 3L framework clarifies the behavioral and structural sources of divergent outcomes and highlights the dynamic implications for decision makers in relation to all the social mechanisms in the system.

Thus, exchange maps (Figures 2 and 3) and a marketing systems map (Figure 1) are innovative and engaging tools for stakeholder conversations around the dynamics and leverage points within a marketing system. Stakeholders can see the system before placing themselves in that system. For the majority, this is their first experience of a systemic or holistic picture of the system they are working in on a daily basis. It is important the map is complex enough to capture what is happening in the system but not so complex it is not comprehendible by stakeholders. A complex but not too complex map avoids map shock and is valuable to the design stage, turning the map into a co-design tool that allows all of the stakeholders to engage with potential change from a bottom up and top-down process.

The governance and regulating stakeholders can focus on policy and structural issues in response to suggestions from incumbents and challengers. For example, the Board of Management and Directors of Nursing can extend the distribution of influenza vaccinations for day and night shifts consistent with practice operational options from nurses, e.g. extend Occupational Health Department opening hours to evening times to cover influenza injections for nighttime nursing staff and/or provide tea/coffee so nurses can go to get the influenza vaccination during their break times. Other challenger resolutions requiring governance and regulating support, responding directly to the dominant dynamics, included the peer-to-peer vaccinations and influenza champions in the wards and units throughout the day and night.

The map with its integrated resolutions is also a valuable tool to introduce new stakeholders, new managers or decision and/or policy makers that need initial insight into influenza vaccinations. The dynamic and detailed knowledge does not have to be lost with staff rotation. Capacity building can continue through the simplification of the influenza stories and narratives.

Over time, a core modelling group can continue, with iterative and participatory activities, to listen, learn and leverage the system as the stakeholders and stakeholder action fields act and react to each other. A core modelling group can also watch for early warning indicators of the dominant dynamics getting worse, the social mechanisms not working, power or conflict struggles in and between the stakeholder action fields or structural inadequacies. For example, peer vaccination and influenza champions were system disruptions that were implementable in the short term. In the main, these worked well in the hospital system. However, using peer vaccination and influenza champions highlighted an anomaly in the system in relation to physiotherapists. Physiotherapists were not classified as nursing healthcare workers, nor did they belong to identified stakeholder action fields. In essence, they formed another stakeholder action field in the system. As a result, a new structure and policy had to be introduced to cater for peer vaccinations to this stakeholder action field in the hospital setting. A ward/unit approach to the manifestation of a new meso level stakeholder action field would inherently capture outlier stakeholders.

Limitations and Further Research

This was a qualitative study to develop a social marketing systems practice for a complex societal challenge. It focused on one focal sub-system, nursing healthcare workers and influenza vaccination. While demonstrating that when the social problem under investigation is sufficiently clear, the creation of a sub-system model and ensuing development of valuable intervention insights is possible. A study of all healthcare workers as a system would potentially uncover dynamics that are more powerful and suggest alternative responses in the quest to reach national and international influenza vaccination rates.

The qualitative stakeholder action field exchange and dynamics mapping undertaken in this case study could be followed by or augmented with quantitative modelling, using tools from system dynamics, such as pathway participation metrics (Oliva and Mojtahedzadeh 2004), and macromarketing methods such as pathway dependency (Layton and Duffy 2018).

A significant limitation in the research was the concentration on barriers to systems change as dictated by the conventional social marketing theory and formative research to address primarily the negative elements of the system blocking the desired behavior. For future research, we recommend inclusion of both the barriers and the enablers at work in a focal marketing system as this would identify not only the negative issues, but also the positive individual and collective elements, if any. It would result in a richer array of reinforcing and balancing loops to provide deeper insights into the evolutionary MAS elements in the system. This is particularly advantageous to social marketing practice that tends to be based on static and retrospective formative research.

Working time was lost to how some definitions from one domain (e.g. macromarketing or social marketing) may have different meanings in another (e.g. public health or system dynamics). For example, a marketing system can include exchange visualizations in the system, while system dynamics visualize stocks and flows to understand the dynamics of a system. Stocks are accumulations or state variables while flows are derivations in a system (Sterman 2000). Construct and operational definitions of key marketing variables would aid marketing systems mapping and time management.

Importantly, the power, tensions, conflicts and cultural conflicts between incumbent, challenger and regulating stakeholders and their stakeholder action fields requires further delineation. Confirming to Layton’s view (2019), how the various stakeholders and networks self-organize and strategic frame the problem is central to the dominant dynamics and thus, the outcomes of any resolutions.

Finally, technology, an emerging secondary social mechanism in Layton’s MAS theory (Layton 2019), is not included in our marketing system map. Technology was evident in singular barrier statements from phase 1 and was proposed as one of the 130 ad hoc activities, e.g. influenza vaccination tablets instead of influenza vaccination injections. However, technology did not emerge as a sufficiently strong dynamic force at work in the marketing system to explain low influenza vaccination rates. Over time, technology may become more important to the behavioral and structural dynamics.

Conclusion

When it comes to understanding marketing systems and associated causal processes, a good starting point is to adopt “as simple as necessary but not simpler” approach. Systems change is a balancing act that requires collective participation to see a marketing system, to listen and learn about the system and to leverage that learning for change as we all live our lives surrounded by stakeholders in systems that influence and shape our daily actions, reactions, choices and behaviors. For marketing systems to contribute to societies in the face of complex societal problems such as obesity, health inequalities and climate change, multi-stakeholder collective change that is systemic and holistic is the way forward. This incorporates multi-societal stakeholder research strategies to provide a rich and informative understanding of the causal dynamics at work between the diverse stakeholders. In turn, understanding the dynamics together with the detailed complexity of a system acts as a strong basis for co-designing and co-creating change strategies for complex problems. Taking the time to analyze stakeholders, to understand their dynamics and understand the system you are in, ultimately gets you more change.

We use Layton’s Mechanism, Action, Structure (MAS) theory to identify the focal marketing system and its boundaries; to understand the dominant dynamics at work in a focal system and to go beyond dyadic exchanges to stakeholder action fields of exchanges involving macro, meso and micro stakeholder relationships relevant to societal betterment. The meso unit of analysis determines the boundaries of the focal marketing system of interest (Baker et al. 2015; Duffy 2016) and acknowledges that marketing system boundaries are embedded (Layton 2019) within other systems, highlighting supervening, adjacent and complementary systems. The dominant dynamics suggest behavioral as well as structural responses. In the quest for understanding marketing systems and systemic change, dynamic models, behavioral and structural, qualitative or quantitative, are powerful.

Footnotes

Authors Note

Christine Fitzgerald is now affilaited with Lifecourse Institute, NUI Galway Ireland and Diarmuid O’ Donovan is now affiliated with Queens University Belfast, UK.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) declared following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The research leading to these results has received funding from the Staff Health and Wellbeing Winter Flu Plan 2016-2017, Saolta Hospital Group, HSE. This publication reflects the views of only the authors, and the HSE cannot be held responsible for any use which may be made of the information contained therein.

ORCID iD

Christine Domegan

References

Acemoglu

Daron

Robinson

James A.

(2019), The Narrow Corridor: States, Societies, and the Fate of Liberty. New York: Penguin Press.

Akkermans

Henk A.

Vennix

Jac A.M.

(1997), “Clients’ Opinion on Group Model-Building: An Exploratory Study,” System Dynamics Review, 13 (1), 3–31.

Alderson

Wroe

(1964), “A Normative Theory of Marketing Systems,” in Theory in Marketing, (2nd series), Cox

Reavis

Alderson

Wroe

Shapiro

Stanley

, eds. Homewood, IL: Richard D. Irwin, 92–108.

Alderson

Wroe

(1965), Dynamic Marketing Behavior: A Functionalist Theory of Marketing. Homewood, IL: Richard D. Irwin.

Arendt

Hannah

(1986), “Communicative Power,” in Power, Lukes

Steven

, ed. New York: New York University Press, 69–74.

Bagozzi

Richard P.

(1974), “Marketing as an Organized Behavioral System of Exchange,” The Journal of Marketing, 38 (4), 77–81.

Bagozzi

Richard P.

(1975), “Marketing as Exchange,” Journal of Marketing, 39 (4), 32–39.

Baker

Stacey Menzel

Hill

Ronald Paul

Baker

Courtney Nations

Mittelstaedt

John D.

(2015), “Improvisational Provisioning in Disaster: The Mechanisms and Meanings of Ad Hoc Marketing Exchange Systems in Community,” Journal of Macromarketing, 35 (3), 334–52.

Batty

Michael

(2007), Cities and Complexity. Boston, MA: MIT Press.

10.

Bérard

Celine

(2010), “Group Model Building Using System Dynamics: An Analysis of Methodological Frameworks,” The Electronic Journal of Business Research Methods, 8 (1), 35–45.

11.

Biroscak

Brian J.

Bryant

Carol A.

Khaliq

Mahmooda

Schneider

Tali

Panzera

Anthony D.

Courtney

Anita

Parvanta

Claudia

Hovmand

Peter S.

(2019), “Using System Dynamics Modeling to Evaluate a Community-Based Social Marketing Framework: A Computer Simulation Study,” Journal of Social Marketing, 9 (1), 53–76.

12.

Biroscak

Brian J.

Schneider

Tali

Panzera

Anthony D.

Bryant

Carol A.

McDermott

Robert J.

Mayer

Alyssa B.

Khaliq

Mahmooda

Lindenberger

James H.

Courtney

Anita H.

Swanson

Mark A.

Wright

Ashton P.

Hovmand

Peter S.

(2014), “Applying Systems Science to Evaluate a Community-Based Social Marketing Innovation: A Case Study,” Social Marketing Quarterly, 20 (4), 247–67.

13.

Borden

D. Scott

Cohn

Scott I.

Gooderham

Christopher

(2018), “Transitioning “Upward” when “Downstream” Efforts are Insufficient,” Social Marketing Quarterly, 24 (3), 151–63.

14.

Bossel

Hartmut

(1999), Indicators for Sustainable Development: Theory, Method, Applications. A Report to the Balaton Group. Winnipeg, Manitoba, Canada: International Institute for Sustainable Development, (accessed March 14, 2020), [available at https://www.iisd.org/pdf/balatonreport.pdf].

15.

Brennan

Linda

Previte

Josephine

Fry

Marie-Louise

(2016), “Social Marketing’s Consumer Myopia,” Journal of Social Marketing, 6 (3), 219–39.

16.

Bryant

Carol A.

Courtney

Anita H.

McDermott

Robert J.

Lindenberger

James H.

Swanson

Mark A.

Mayer

Alyssa B.

Panzera

Anthony D.

Khaliq

Mahmooda

Schneider

Tali

Wright

Ashton P.

Craig Lefebvre

Biroscak

Brian J.

(2014), “Community-based Prevention Marketing for Policy Development: A New Planning Framework for Coalitions,” Social Marketing Quarterly, 20 (4), 219–46.

17.

Bryson

John M.

(2004), “What to Do When Stakeholders Matter?” Public Management Review, 6 (1), 21–53.

18.

Byrne

David

Callaghan

Gill

(2014), Complexity Theory and the Social Sciences – The State of the Art. New York: Routledge.

19.

Conejo

Francisco

Wooliscroft

Ben

(2015), “Brands Defined as Semiotic Marketing Systems,” Journal of Macromarketing, 35 (3), 287–301.

20.

Coyle

R. G.

(1996), System Dynamics Modelling: A Practical Approach. London: Chapman & Hall.

21.

Dini

Guglielmo

Toletone

Alessandra

Sticchi

Laura

Orsi

Andrea

Bragazzi

Nicola Luigi

Durando

Paolo

(2018), “Influenza Vaccination in Healthcare Workers: A Comprehensive Critical Appraisal of the Literature,” Human Vaccines and Immunotherapeutics, 14 (3), 772–89.

22.

Dixon

Donald F.

(1967), “A Social Systems Approach to Marketing,” Social Science Quarterly, 48 (2), 164–73.

23.

Domegan

Christine

McHugh

Patricia

Biroscak

Brian Joseph

Bryant

Carol

Calis

Tanja

(2017), “Non-linear Causal Modeling in Social Marketing for Wicked Problems,” Journal of Social Marketing, 7 (3), 305–29.

24.

Domegan

Christine

McHugh

Patricia

Devaney

Michelle

Duane

Sinead

Hogan

Michael

Broome

Benjamin J.

Layton

Roger A.

Joyce

John

Mazzonetto

Marzia

Piwowarczyk

Joanna

(2016), “Systems-thinking Social Marketing: Conceptual Extensions and Empirical Investigations,” Journal of Marketing Management, 32 (11-12), 1123–44.

25.

Duffy

Sarah Maree

(2016), New Perspectives on Marketing Systems: An Investigation of Growth, Power, Social Mechanisms, Structure and History. Doctoral dissertation, University of New South Wales, School of Business, Sydney, Australia.

26.

Duffy

Sarah Maree

Northey

Gavin

Esch

Patrick van

(2017), “Iceland: How Social Mechanisms Drove the Financial Collapse and Why it’s a Wicked Problem,” Journal of Social Marketing, 7 (3), 330–46.

27.

Duffy

Sarah Maree

Esch

Patrick van

Yousef

Murooj

(2020), “Increasing Parental Leave Uptake: A Systems Social Marketing Approach,” Australasian Marketing Journal, https://doi.org/10.1016/j.ausmj.2020.01.007.

28.

European Centre for Disease Prevention and Control (2017), Seasonal Influenza Vaccination in Europe. Vaccination Recommendations and Coverage Rates in the EU Member States for Eight Influenza Seasons: 2007-2008 to 2014-2015. Technical Report . Stockholm, Sweden: ECDC, (accessed March 14, 2020), [available at https://www.ecdc.europa.eu/sites/default/files/documents/influenza-vaccination-2007%E2%80%932008-to-2014%E2%80%932015.pdf].

29.

Fisk

George

(1967), Marketing Systems. New York: Harper & Row.

30.

Fisk

George

(1981), “An Invitation to Participate in Affairs in the Journal of Macromarketing,” Journal of Macromarketing, 1 (1), 3–6.

31.

French

Jeff

Gordon

Ross

(2015), Strategic Social Marketing. Thousand Oaks: Sage.

32.

Georgopoulos

Basil S.

Matejko

Aleksander

(1967), “The American General Hospital as a Complex Social System,” Health Service Review, 2 (1), 76–112.

33.

Giesler

Markus

Fischer

Eileen

(2017), “Market System Dynamics,” Marketing Theory, 17 (1), 3–8.

34.

Gordon

Ross

Butler

Katherine

Cooper

Paul

Waitt

Gordon

Magee

Christopher

(2018), “Look before you LIEEP: Practicalities of Using Ecological Systems Social Marketing to Improve Thermal Comfort,” Journal of Social Marketing, 8 (1), 99–119.

35.

Harkin

Katharine

(2018), Seasonal Influenza Vaccination for Nurses, Breaking down the Barriers. Doctoral dissertation, Faculty of Public Health Medicine of the Royal College of Physicians of Ireland .

36.

Hastings

Gerard

Domegan

Christine

(2018), Social Marketing: Rebels with a Cause. Abingdon: Routledge.

37.

HSE-Health Protection Surveillance Centre (2016), Uptake of the seasonal influenza vaccine in acute hospitals and long-term care facilities in Ireland, 2015-2016, (accessed March 14, 2020), [available at https://www.hpsc.ie/a-z/respiratory/influenza/seasonalinfluenza/influenzaandhealthcareworkers/hcwinfluenzavaccineuptakereports/].

38.

Huff

Aimee Dinnin

Barnhart

Michelle

McAlexander

Brandon

McAlexander

Jim

(2017), “Addressing the Wicked Problem of American Gun Violence: Consumer Interest Groups as Macro-Social Marketers,” Journal of Macromarketing, 37 (4), 393–408.

39.

Humphreys

Ashlee

(2010), “Megamarketing: The Creation of Markets as a Social Process,” Journal of Marketing, 74 (2), 1–19

40.

Hunt

Shelby D.

(1976), “The Nature and Scope of Marketing,” Journal of Marketing, 40 (3), 17–28.

41.

Hunt

Shelby D.

(1981), “Macromarketing as a Multidimensional Concept,” Journal of Macromarketing, 1 (1), 7–8.

42.

Jagadale

Sujit Raghunathrao

Kadirov

Djavlonbek

Chakraborty

Debojyoti

(2018), “Tackling the Subaltern Quandary: Marketing Systems of Dignity,” Journal of Macromarketing, 38 (1), 91–111.

43.

Jordan

Jeffrey

(2019), “Telling Stories that Change People,” Keynote address, World Social Marketing Conference , Edinburgh, UK, June 5th.

44.

Kemper

Joya A.

Ballantine

Paul W.

(2017), “Socio-technical Transitions and Institutional Change: Addressing Obesity through Macro-Social Marketing,” Journal of Macromarketing, 37 (4), 381–92.

45.

Kennedy

Ann-Marie

(2016), “Macro-social marketing,” Journal of Macromarketing, 36 (3), 354–65.

46.

Kennedy

Ann-Marie

(2017), “Macro-social Marketing Research: Philosophy, Methodology and Methods,” Journal of Macromarketing, 37 (4), 347–55.

47.

Kennedy

Ann-Marie

Parsons

Andrew Grant

(2012), “Macro-social Marketing and Social Engineering: A Systems Approach,” Journal of Social Marketing, 2 (1), 37–51.

48.

Kennedy

Ann-Marie

Kemper

Joya A.

Parsons

Andrew Grant

(2018), “Upstream Social Marketing Strategy,” Journal of Social Marketing, 8 (3), 258–79.

49.

Kennedy

Ann-Marie

Kapitan

Sommer

Bajaj

Neha

Bakonyi

Angelina

Sands

Sean

(2017), “Fast Fashion, a Wicked Problem for Macro-Social Marketing,” in Social Marketing: Rebels with a Cause, Hastings

Gerard

Domegan

Christine

, eds. Abingdon: Routledge, 502–08

50.

Kleidon

Axel

(2016), Thermodynamic Foundations of the Earth System. Cambridge: Cambridge University Press.

51.

Kunc

Martin

(2012), “Teaching Strategic Thinking Using System Dynamics: Lessons from a Strategic Development Course,” System Dynamics Review, 28 (1), 28–45.

52.

Kunc

Martin

Morecroft

John

(2007), “System Dynamics Modelling for Strategic Development,” in Supporting Strategy: Frameworks, Methods and Models, O’Brien

Frances A.

Dyson

Robert G.

, eds. Chichester: John Wiley & Sons, 157–90.

53.

Kuster

Stefan

Shah

Prakesh S.

Coleman

Brenda

Lam

Po-Po

Tong

Agnes

Wormsbecker

Anne

McGee

Allison

(2011), “Incidence of Influenza in Healthy Adults and Healthcare Workers: A Systematic Review and Meta-Analysis,” PLoS ONE 6(10): e26239. doi:10.1371/journal.pone.0026239.

54.

Langworth

Richard M.

(ed) (2008), Churchill by Himself. The Definitive Collection of Quotations. New York: Public Affairs.

55.

Layton

Roger A.

(2007), “Marketing Systems – A Core Macromarketing Concept,” Journal of Macromarketing, 27 (3), 227–42.

56.

Layton

Roger A.

(2008), “The Search for a Dominant Logic: A Macromarketing Perspective,” Journal of Macromarketing, 28 (3), 215–27.

57.

Layton

Roger A.

(2011), “Towards a Theory of Marketing Systems,” European Journal of Marketing, 45 (1/2) 259–76.

58.

Layton

Roger A.

(2015), “Formation, Growth and Adaptive Change in Marketing Systems,” Journal of Macromarketing, 35 (3), 302–19.

59.

Layton

Roger A.

(2016), “There Could Be More to Marketing than You Might Have Thought!” Australasian Marketing Journal, 24 (1), 2–7.

60.

Layton

Roger A.

(2019), “Marketing Systems – Looking Backward, Sizing up and Thinking Ahead,” Journal of Macromarketing, 39 (2), 208–24

61.

Layton

Roger A.

Grossbart

Sanford

(2006), “Macromarketing: Past, Present, and Possible Future,” Journal of Macromarketing, 26 (2), 193–213.

62.

Layton

Roger A.

Duffy

Sarah Maree

(2018), “Path Dependency in Marketing Systems - where History Matters and the Future Casts a Shadow,” Journal of Macromarketing, 38 (4), 400–14.

63.

Lazer

William

(1971), Marketing Management: A Systems Perspective. New York: John Wiley and Sons.

64.

Leveson

Nancy

Samost

Aubrey

Dekker

Sidney

Finkelstein

Stan

Raman

Jaishankar

(2016), “A Systems Approach to Analyzing and Preventing Hospital Adverse Events,” Journal of Patient Safety, 12 (1), 1–6.

65.

Löbler

Helge

(2016), “Marketing as a Social Science – Comments to Roger Layton’s Article: “There Could Be More to Marketing Than You Might Have Thought!” Australasian Marketing Journal, 3 (24), 244–46.

66.

Luca

Nadine

Hibbert

Sally

McDonald

Ruth

(2015), “Towards a Service-Dominant Approach to Social Marketing,” Marketing Theory, 16 (2), 194–218.

67.

McHugh

Patricia

Domegan

Christine

Mazzonetto

Marzia

Duane

Sinead

Joyce

John

Devaney

Michelle

Hogan

Michael

Broome

Benjamin J.

Piwowarczyk

Joanna

(2017), “Seas of Energy: Using a Systems Research Approach for a Wicked Problem,” in Social Marketing: Rebels with a Cause, Hastings

Gerard

Domegan

Christine

, eds. Abingdon: Routledge, 329–38.

68.

McKenzie-Mohr

Doug

Wesley Schultz

(2014), “Choosing Effective Behavior Change Tools,” Social Marketing Quarterly, 20 (1), 35–46.

69.

Mittelstaedt

John D.

Clifford

Shultz

William Kilbourne

II Peterson

Mark

(2014), “Sustainability as Megatrend: Two Schools of Macromarketing Thought,” Journal of Macromarketing, 34 (3), 253–64.

70.

Mohr

Jeff

Mohr

Ryan

(2011), Kumu (Personal Version), (accessed March 14, 2020), [available at https://kumu.io].

71.

Oliva

Rogelio

Mojtahedzadeh

Mohammad

(2004), “Keep it Simple: Dominance Assessment of Short Feedback Loops,” in Proceedings of the 22nd International System Dynamics Society Conference, July 25-29, Keble College, Oxford University, Oxford, UK.

72.

Parsons

Talcott

(1963), “On the Concept of Political Power,” Proceedings of the American Philosophical Society, 107 (3), 232–62.

73.

Peterson

Mark

(2013), Sustainable Enterprise: A Macromarketing Approach. London: Sage.

74.

Peterson

Steve

(2004), “Applying System Dynamics to Public Policy: The Legacy of Barry Richmond,” The Systems Thinker, 15 (4), 1–7.

75.

Pettigrew

Simone

Roberts

Michele

(2011), “Qualitative Research Methods in Social Marketing,” in The SAGE Handbook of Social Marketing, Hastings

Gerard

Angus

Kathryn

Bryant

Carol

, eds. Thousand Oaks, CA: Sage, 208–23.

76.

Quintyne

Keith Ian

Daly

Brabazon

Elaine

Finnegan

Peter

Kavanagh

Paul

(2018), “Attitudes and Uptake of Seasonal Influenza Vaccination for Health Service Executive (HSE) Staff,” Irish Medical Journal, 111 (5), 749.

77.

Ricigliano

Robert

(2016), Making Peace Last: A Toolbox for Sustainable Peacebuilding. Abingdon: Routledge.

78.

Scharmer

Otto

Kaufer

Katrin

(2013), Leading from the Emerging Future, From Ego-System to Eco-System Economics. Oakland, CA: BK Currents Book.

79.

Senge

Peter

(1990), The Fifth Discipline: The Art and Practice of the Learning Organization. New York: Currency Doubleday.

80.

Shaw

Eric

Jones

Brian

(2005), “A History of Schools of Marketing Thought,” Marketing Theory, 5 (3), 239–82

81.

Shultz

Clifford J.

II Rahtz

Don

Sirgy

Joseph M.

(2017), “Distinguishing Flourishing from Distressed Communities: Vulnerability, Resilience, and a Systemic Framework to Facilitate Well-Being,” in The Handbook of Community Well-Being, Rhonda Phillips and Cecilia Wong, eds. Dordrecht, Netherlands: Springer, 403–22.

82.

Spencer

James H.

Finucane

Melissa L.

Fox

Jefferson M.

Saksena

Sumeet

Sultana

Nargis

(2020), “Emerging Infectious Disease, the Household Built Environment Characteristics, and Urban Planning: Evidence on Avian Influenza in Vietnam,” Landscape and Urban Planning, 193, 103681.

83.

Sterman

John

(2000), Business Dynamics: Systems Thinking and Modelling for a Complex World. Boston, MA: Irwin/McGraw-Hill.

84.

Sterman

John

(2018), “System Dynamics at Sixty: The Path Forward,” System Dynamics Review, 34 (1/2), 5–47.

85.

Tapp

Alan

(2018), Why Marketers Don’t Get Hugged at Parties - And Other Useful Things about Social Marketing, keynote speech presented at the 8th Annual Social Marketing Conference, National University of Ireland Galway, Galway, Ireland, May 24, 2018, (accessed March 14, 2020), [available at https://www.youtube.com/watch?v=BQu8m-warWk&feature=youtu.be].

86.

Torres

Juan P.

(2019), “System Dynamics Review and Publications 1985–2017: Analysis, Synthesis and Contributions,” System Dynamics Review, 35 (2), 160–76.

87.

Truong

V. Dao

(2017), “Government-Led Macro-Social Marketing Programs in Vietnam: Outcomes, Challenges, and Implications,” Journal of Macromarketing, 37 (4), 409–25.

88.

Truong

V. Dao

Saunders

Stephen Graham

Dam Dong

(2019), “Systems Social Marketing: A Critical Appraisal,” Journal of Social Marketing, 9 (2), 180–203.

89.

Vargo

Stephen L.

Koskela-Huotari

Kaisa

Baron

Steve

Edvardsson

Reynoso

Javier

Colurcio

Maria

(2017), “A Systems Perspective on Markets – Toward a Research Agenda,” Journal of Business Research, 79, 260–68.

90.

Venturini

Roberto

(2016), “Social Marketing and Big Social Change: Personal Social Marketing Insights from a Complex System Obesity Prevention Intervention,” Journal of Marketing Management, 32 (11-12), 1190–99.

91.

Warfield

John N.

Roxana Cárdenas

(2002), A Handbook of Interactive Management. Palm Harbor, FL: Ajar Publishing Company.

92.

WHO Regional Office for Europe (2015), Tailoring Immunization Programmes for Seasonal Influenza (TIP FLU): Understanding Health Care Workers’ Uptake of Season Al Influenza Vaccination in Montenegro: A Case Study for Policy-Makers and Programme Managers. Copenhagen, Denmark: WHO Regional Office for Europe, (accessed March 14, 2020), [available at http://www.euro.who.int/__data/assets/pdf_file/0007/281860/Tailoring-Immunization-Programmes-Seasonal-Influenza-TIP-FLU.pdf].

93.

Wolstenholme

Eric F.

(1999), “Qualitative vs Quantitative Modelling: The Evolving Balance,” The Journal of the Operational Research Society, 50 (4), 422–28.

94.

Wooliscroft

Ben

Ganglmair-Wooliscroft

Alexandra

(2018), “Growth, Excess and Opportunities: Marketing Systems’ Contributions to Society,” Journal of Macromarketing, 38 (4), 355–63.

95.

Wooliscroft

Ben

Wührer

Gerhard

(2016), “Macromarketing is What Macromarketers Do”, so what did Macromarketers Do?” A Bibliometric Analysis of the Journal of Macromarketing, the Years 1981 to 2015,” in Proceedings of the 41st Annual Macromarketing Conference, Trinity College, Dublin, Ireland, July 15.

96.

World Health Organization (2019a), Global influenza strategy 2019-2030. Geneva, Switzerland: World Health Organization, (accessed March 14, 2020), [available at https://apps.who.int/iris/bitstream/handle/10665/311184/9789241515320-eng.pdf?sequence=18&isAllowed=y].

97.

World Health Organization (2019b), How to implement seasonal influenza vaccination of health workers: An introduction manual for national immunization programme managers and policy makers. Geneva, Switzerland: World Health Organization, (accessed March 14, 2020), [available at https://apps.who.int/iris/bitstream/handle/10665/325906/9789241515597-eng.pdf?ua=1].

98.

Wymer

Walter

(2011), “Developing More Effective Social Marketing Strategies,” Journal of Social Marketing, 1 (1), 17–31.

99.

Zurcher

Kathleen A.

Jensen

Jon

Mansfield

Ann

(2018), “Using a Systems Approach to Achieve Impact and Sustain Results,” Health Promotion Practice, 19 (Suppl 1), 15S–23S.