Social Marketing for Social Change

The Development of Social Marketing: Downstream, Midstream, and Upstream

Social marketing has been around for nearly half a century following Kotler and Zaltman’s ground-breaking (1971) article “Social marketing: An approach to planned social change.” It is interesting this pioneering article linked the concept of social marketing with social change. However, their conceptualization of social marketing as the selling of “ideas” shifted over time to focus on voluntary individual behavior change (Andreasen, 1994). Writing in this journal, Smith (2002) agrees with this definition and argues social marketing can help bring about social change through promoting the behavior change of individuals. More recent definitions of social marketing have continued to look at the individual and to evaluate how commercial marketing principles and practices can be applied to achieve social good (Spotswood, French, Tapp, & Stead, 2012). However, Wallack (2002) counters this view and argues the major influences on health are social and political. Public health, he believes, is committed to social change and aims to reduce health inequality. To achieve social change, public health (and therefore social marketing) should seek to influence public policy and reduce the barriers to opportunities rather than attempting to improve individual health conditions. While downstream social marketing focuses on the individual, and places responsibility for change with the consumer, he advocates an “upstream” approach to public health, which mirrors developments in social marketing theory. Upstream and downstream are terms used in a public health metaphor to describe two alternate approaches to preventing and dealing with health issues (Gordon, 2013; Donovan & Henley, 2010; Dorfman, 2003; Wallack, 2002). Some social marketers have also called for the development of upstream approaches, with the aim of influencing the behavior of policy makers and decision makers to create a more favorable environment in which individuals find themselves (Andreasen, 2006; Gordon, 2011, 2012, 2013; Hoek & Jones, 2011; Wood, 2012). Decision-making groups include politicians, media figures, community activists, corporations, schools, and foundations (Gordon, 2013; Kotler & Lee, 2008). Recent developments in social marketing theory include the need to understand the behavior of service organizations and staff to enable the cocreation of customer-oriented services (“midstream” social marketing; Russell-Bennett, Wood, & Previte, 2013; Zainuddin, 2013).

In moving beyond individually focused strategies, which risk solely “blaming” individuals for the current standard of health and social well-being in a community, social marketers can also enable individuals to make healthier choices by improving the environment, addressing inequalities, and encouraging policy makers to address the underlying causes of health and social problems. There is a clear association between most health and social issues (obesity, smoking, alcohol, drugs, teenage pregnancy, etc.) and deprivation (Pickett, Kelly, Brunner, Lobstein, & Wilkinson, 2005). Individuals and their families who face poverty, unemployment, poor housing, and inadequate education are much more likely to experience the issues and problems which become the target of social marketing interventions. Behaviors such as smoking, eating “junk” food, and alcohol consumption may offer short-term benefits to individuals who are struggling to survive and may be suffering from depression or mental illness (Strine, Chapman, Balluz, Moriarty, & Mokdad, 2008). They are unable or unwilling to consider the long-term consequences of their actions, which are understandable in the circumstances. Commercial companies are more-or-less free to market harmful products and brands (tobacco, alcohol, and high-fructose food and drinks) to potentially vulnerable people who may lack the education, resources, and resilience to make healthy choices. Attempting to change specific individual behaviors, while ignoring their underlying socioeconomic and environmental bases, is illogical and often ineffectual: Social marketing is treating the symptoms rather than the underlying causes.

In acknowledging these broader, deeper influences on behavior, Domegan (2008, p. 137) discusses macrosocial marketing—the use of social marketing approaches at the societal level by “those who control the social context.” According to Kennedy and Parsons (2012), macrosocial marketing is different from upstream social marketing because it is government led and “seeks macro levels of change” (p. 40). This is a moot point; it could be argued upstream social marketing is the means of achieving change at the macrosocietal level. Nevertheless, Kennedy and Parsons’ (2012) systems perspective is an important contribution to social marketing theory. They argue macrosocial marketing is part of wider social engineering initiatives or “arranging and channelling environmental and social forces to create high probability that effective social action will occur” (p. 41). The three levels of social marketing activity discussed here can also be interpreted using social–ecological models, which are discussed in the next section.

Ecological Models and Social Marketing

Originally developed to describe biological ecosystems, Bronfenbrenner (1977) is widely credited for applying this systems thinking to child development and family welfare: OPEN IN VIEWER

According to Sallis, Owen, and Fisher (2008, p. 446), there are four core principles of ecological models when applied to health behavior:

There are multiple influences on specific health behaviors, including factors at the intrapersonal, interpersonal, organizational, community, and public policy levels.

The individual is at the heart of a nested series of ever-widening environmental influences starting with family, friends, and school, which are situated within the microsystem. This is the level in which most (downstream) social marketing operates, targeting the individual—possibly, but not always—within the context of a family, school, or work microsystem. Kennedy and Parsons (2012) thus describe this as “microsocial marketing.” However, the influences on behavior change are generally too complex and powerful to succeed through microsocial marketing alone. The ultimate purpose of ecological models of health behavior is to inform the development of comprehensive intervention approaches that can systematically target mechanisms of change at several levels of influence (Sallis, Owen, & Fisher, 2008). Behavior change is more likely when environments and policies support healthful choices, when social norms and social support for healthy choices are strong, and when individuals are motivated and educated to make those choices. Interactions between various microsystems create the mesosystem and outside of this the exosystem comprises organizations and networks which the individual may not be directly part of but which can still influence his or her behavior. The importance of the exosytem is recognized in community-based social marketing (Bryant, Forthofer, Brown, Landis, & McDermott, 2000; McKenzie-Mohr, 2013) and could also include midstream social marketing as defined above (Russell-Bennett et al., 2013). At the broadest level, the macrosystem compromises wider social, cultural, and political/legal/economic forces which influence all individuals, groups, and organizations within the social–ecological system. Macro and upstream social marketing should operate at this level, although how to do this effectively is not always clear (Domegan, 2008; Gordon, 2013).

The ecological model has been applied in social marketing to evaluate obesity interventions (Dooyema, Belay, Foltz, Williams, & Blanck, 2013; Gentile et al., 2009; Hawkins, Cole, & Law, 2009; Lytle, 2009; Swinburn, Egger, & Raza, 1999), nutrition programs (Gregson et al., 2001), and physical activity interventions (Elder et al., 2007; Langille & Rodgers, 2010). However, the main benefit of using a socioecological approach is to help social marketers understand the underlying determinants of health and general life outcomes. An additional “layer”—the chronosystem—explains changes which occur as human beings develop from birth through to adulthood and the lasting impact of historic events on families and individuals (Bronfenbrenner, 1986). In particular, early years’ experiences are crucial in determining long-term outcomes, including most health issues which may become the focus of downstream individual behavior-change social marketing programs in later life. The following section discusses important research studies which have used an ecological approach to highlight the critical role of ECEC in shaping individual behaviors and life outcomes.

ECEC

Research demonstrates many of life’s outcomes are determined by events that may or may not happen within a child’s microsystem as he or she develops during early years (Bronfenbrenner, 1977, 1986). Cognitive and linguistic abilities are shaped at this time and reflect changes and synaptic connections within the brain (Ramey & Ramey, 1998). These in turn are largely determined by ECEC experiences in the home and in preschool settings (Burger, 2010; Field, 2010; Melhuish et al., 2008). Children who benefit from a stimulating home environment and a good quality preschool educational experience are likely to develop more quickly than those who do not. The impact of these inputs in the child’s microsystem is long-lasting and far reaching. Not only do they do better at school as they progress into primary, then secondary education, but their life outcomes are positively enhanced. Longitudinal studies demonstrate that positive early-years inputs can significantly improve health, social, and economic outcomes while reducing the presence of risk factors such as crime, smoking, alcohol/drug abuse, poor diet, and lack of exercise (Campbell et al., 2012; Ramey & Ramey, 1998; Schweinhart et al., 2005). A particularly informative intervention based on Bronfenbrenner’s framework was the Abecedarian project, which involved an Early Child Development (ECD) initiative in a poor African American population in North Carolina and was the subject of a longitudinal study tracking participants through to adulthood (Campbell & Ramey, 1994; Ramey & Campbell, 1991; Ramey et al., 2000). The 111 children, whose mothers had a low intelligence quotient and low income, were randomized into two groups. One group was placed in an ECD program that involved center-based care and home visits beginning at 3 months of age and continuing until the children entered school. The control group received family support, social services, low-cost or free pediatric care, and child nutritional supplements but no additional childcare. The program had one qualified early childhood educator for every three infants and toddlers until age 3 and one for every six children over age 3. The children participating in the ECD program showed significant relative gains in cognitive development, educational performance, and improved behavior that were still evident when they became adults. At the age of 21, 104 of the original 111 infants in the Abecedarian Project were measured for cognitive functioning, academic skills, educational attainment, employment, parenthood, and social adjustment (Campbell, Ramey, Pungello, Sparling, & Miller-Johnson, 2002; Clarke & Campbell, 1998). At that time, researchers found:

Participants had significantly higher cognitive, reading, and maths scores as toddlers through to age 21 than the control group.

Some of these findings confirm the potential health benefits of early years interventions, and a follow-up study of the participants at age 30 noted improved reports of physical health among the participants compared to the control group (Campbell et al., 2012). Children who are at risk through a lack of appropriate parental inputs and stimuli can benefit enormously from a preschool educational program. In fact, there is compelling evidence that socioeconomic disadvantage and inequality—including health inequality—can be overcome through good quality preschool education and professional relationships (Braveman, Egerter, Woolf, & Marks, 2011). A meta-analysis of 125 studies conducted by Oberklaid, Baird, Blair, Melhuish, and Hall (2013) concluded preschool was associated with substantial benefits for cognitive and socioemotional outcomes often through to adulthood, and those with an educational emphasis had larger effect sizes. For example, a large-scale ECEC intervention for disadvantaged children demonstrated later benefits in adulthood in terms of higher educational achievement and socioeconomic status, improved health, and less participation in crime (Reynolds, Temple, Ou, Arteaga, & White, 2011). Research in North America, Scandinavia, Africa, England, and Northern Ireland consistently demonstrates children who have experienced effective preschool education develop more quickly, have improved literacy and numeracy skills, and are more likely to become successful, healthy adults (Campbell et al., 2012; Melhuish, 2004; Ramey & Campbell, 1984). They are less likely to adopt the harmful lifestyles and behaviors that frequently become the target of social marketing interventions.

Tackling the Obesity Crisis—Social Determinants and Individual Behavior Change

According to the World Health Organization (WHO, 2003), obesity is one of the most significant global problems we face in the 21st century. In the United Kingdom, the obesity intervention Change4Life was the first strategic national social marketing campaign developed as part of government policy (Department of Health [DH], 2009). It was based on a thorough consumer insight study and segmentation analysis (DH, 2008), in line with the National Social Marketing Centre’s Benchmark Criteria (French & Blair-Stevens, 2007). The intention was to use social marketing to encourage and enable individuals and families to eat a healthier diet and become more physically active. However, obesity levels continue to rise in the United Kingdom (National Health Service, 2011): According to the latest WHO projections, 74% (36%) of men and 64% (33%) of women in the United Kingdom will be overweight (obese) by 2030 (WHO, 2015). The fundamental objective of Change4Life and its underlying government policy to halt this trend has not been achieved. Ecological approaches help us to understand the many risk factors for obesity and why downstream social marketing alone cannot succeed in tackling obesity (Birch & Ventura, 2009; O’Brien et al., 2007; Story, Kaphingst, Robinson-O’Brien, & Glanz, 2008). For example, Hawkins, Cole, and Law (2009) analyzed data from the UK Millennium Cohort Study to understand the factors which contributed to overweight or obesity in children aged 3. They were able to examine individual, family, community, and area-level risk factors and found evidence that obesity prevention should start in early life. In particular, their findings suggest interventions should target parents and help to support them in developing healthy behaviors and weight during and after pregnancy. They argue the ecological approach is required to tackle a complex issue like obesity and requires action across various government departments, for example, paid parental maternity leave, policy to improve work/life balances, and legislation/intervention to promote breast feeding. In general, they suggest (p. 154) “policies and interventions should focus on parents and providing them with an environment to support healthy behaviours for themselves and their children.”

Birch and Ventura (2009) use an ecological model to critically evaluate the obesogenic environment in which families find themselves in much of the developed world. They show how traditional parenting and child-feeding practices, which developed over centuries of food scarcity, contribute to obesity. They argue obesity interventions must start at an early age and should take place in family and community contexts, not just schools (the place for most social marketing initiatives). Other researchers highlight macroenvironmental forces, particularly commercial marketing’s role in helping create an “obesogenic environment” (Swinburn et al., 1999). According to Hanratty, Milton, Ashton, and Whitehead (2012), this environment encourages the overconsumption of energy-dense foods and discourages physical activity. These macroenvironmental forces mean it is frequently very difficult for certain groups and individuals to make healthy choices, leading them and their children to become overweight. Regulatory actions from governments and increased efforts from industry and civil society will be necessary to break these vicious cycles (Roberto et al., 2015; Swinburn et al., 2015). Critical social marketers (Gordon, 2011) and those calling for a shift in focus to upstream behavior change propose measures such as restricting the marketing of unhealthy food to children, making healthier food more affordable, for example, through subsidies on fruit and vegetables, and making less healthy food more expensive by using taxes, for example, on sugary drinks (Hawkes et al., 2015; Kapetanaki, Brennan, & Caraher, 2014; Kleinert & Horton, 2015; Wymer, 2010). WHO (2010) published a set of guidelines to help policy makers regulate the marketing of food and drink products to children. This is resisted by companies, and to an extent governments, who tend to favor voluntary agreements. However, there is little systematic evidence for the effectiveness of these voluntary measures, which do not include more radical changes in pricing, marketing regulation, and sugar content (Knai et al., 2015).

In fact, rather than increased regulation, some legislative changes are potentially exacerbating the obesogenic environment. For example, the European Union (EU) recently announced it was to allow a “health claim” for fructose, a sweetener linked with rising obesity levels in the United States (European Commission, 2013). Many believe the use of high-fructose corn syrup (HFCS) has caused obesity to rise faster in the United States than elsewhere in the world (Bray, Nielsen, & Popkin, 2004; Popkin & Nielsen, 2003). According to Bray, Nielsen, and Popkin (2004), changes in diet since World War II and the increased use of HFCS mirrors the rapid increase in obesity. They argue the digestion, absorption, and metabolism of fructose differ from those of glucose and that dietary fructose may contribute to increased energy intake and weight gain. In contrast, Europe has largely used cane and beet sugar instead. Now the EU has decided food and drink manufacturers can claim their sweetened products are healthier if they replace more than 30% of the glucose and sucrose they contain with fructose. The decision was taken on the advice of the European Food Safety Authority (2011) on the grounds that fructose has a lower glycemic index—it does not cause as high and rapid a blood sugar spike as sucrose or glucose. However, Popkin, Bray, and Hu (2014) argue this ignores the wider and more important public health issue that we should all consume less fructose and other sugars. Other obesity experts believe in the long-term, excess fructose causes more damage to the body than other sugars (Goran, Ulijaszek, & Ventura, 2013). Furthermore, calorically sweetened beverages may enhance caloric overconsumption, contributing to “the sweetening of the world’s diet” (Popkin & Nielsen, 2003). So, the increase in consumption of HFCS—in particular, the overconsumption of HFCS in calorically sweetened beverages—is related to the growth in obesity.

Roberto et al. (2015) explored the dichotomy of individual versus environmental drivers of obesity, concluding that although individuals bear some personal responsibility for their health, environmental factors can readily support or undermine their ability to act in their own self-interest. They argue contemporary food environments exploit people’s biological, psychological, social, and economic vulnerabilities, making it easier for them to eat unhealthy foods. This reinforces preferences and demands for foods of poor nutritional quality, furthering the unhealthy food environments. Many of these products are specifically marketed to children and/or their parents. We also know that socioeconomic background and childhood development have profound influence on future life outcomes, including health issues such as obesity (Hawkins et al., 2009; Knai, Lobstein, Darmon, Rutter, & McKee, 2012; Pickett et al., 2005; Walsh & Cullinan, 2015). In their ecological study, Story, Kaphingst, Robinson-O’Brien, and Glanz (2008) pointed out the disparities in food access for low-income and minority groups. The social determinants of health were acknowledged in the UK Government’s review of health inequalities, which resulted in the crucial Marmot Report (Commission on Social Determinants of Health, 2008; Marmot & Bell, 2012; Marmot et al., 2008). Families from deprived areas are more likely to be overweight than those from professional classes (Knai et al., 2012; Walsh & Cullinan, 2015; Williams & Kumanyika, 2003). So, there are upstream macrosocial and policy issues to consider when developing social marketing obesity interventions.

Jones-Taylor (2015) argues ECEC initiatives discussed earlier not only lead to the well-documented higher educational attainment, better jobs, higher salaries, and less crime, they also reduce the risk of obesity. ECEC programs play a central role in establishing healthy eating habits and regular physical activity. This leads to a call for high-quality training of ECEC providers to enable them to implement strategies for healthy eating and exercise (Foster et al., 2015; Tovar et al., 2015). To address the obesity crisis, policies must be in place to promote healthy eating and physical activity in the early years of life, to train ECEC staff, and to engage and integrate parents and families as equal partners (Jones-Taylor, 2015).