Social marketing for public health Moloney

Marketing techniques and tools, imported from the private sector, are increasingly being advocated for their potential value in crafting and disseminating effective social change strategies. This paper describes the field of social marketing as it is used to improve the health of the public. A disciplined process ofstrategic planning can yield promising new insights into consumer behavior and product design. But the “technology” cannot simply bc transferred without some translation to reconcile differences between commercial marketing and public health. Beginning in the mid-1970s the belief began to take hold that most of what we must do in this country to improve health on a meaningful scale is to persuade all Americans to make enduring changes in their personal habits and lifestyles: to reduce drinking, modify diet, become physically active, quit smoking and using drugs, seek out screening and preventive health services, and generally exercise caution-on the highways, in sexual encounters, in handling anger and stress, on the job, out in the sun, wherever danger attends. From this formulation of the problem, it seemed a logical step to solutions that would borrow techniques from the management sciences and commercial marketing-they who have elevated mass persuasion to a high art form. Over the past two decades social marketing has come of age as a consumer-focused approach to the question of how to “go to scale” in efforts to conserve and advance the health of the population. The term appears with increasing frequency in the health literature, where marketing is being advocated as a powerful set of tools for segmenting, profiling, and targeting populations; designing, positioning, testing, and refining products and services; and sometimes galvanizing community action or shaping policy. This paper examines the uses of social marketing to advance public health. We draw on three major bodies of information. First, we surveyed the major textbooks and conference proceedings that have been codifying marketing practices for the health field. Second, with an eye to crosscutting themes, we reviewed applications in five areas: (1) maternal and child health and nutrition in the third world, (2) family planning in developing countries, (3) the antismoking campaign in the United States, (4) cardiovascular disease risk reduction, and (5) substance abuse prevention among adolescents. Finally, we conducted telephone interviews with more than thirty practitioners and scholars recognized for their work in developing, applying, and/ or evaluating health-focused campaigns that use marketing techniques or the mass media. Based on that exploration, we offer a brief overview of the historical convergence of marketing and health promotion; the essential elements of a social marketing approach to health; lessons learned from applications of social marketing to health; and limitations, caveats, and issues for the future. We believe that the time is right for public health to learn what marketing has to teach. Because the fit is less than perfect, the lessons will on O cber 3, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom 106 HEALTH AFFAIRS | Summer 1993 need translation; they cannot simply be transferred. Marketing Comes To Health The conditions for a convergence of private-sector marketing and public health grew out of historical trends in the two spheres. In health, the well-documented demographic transition from an era of acute infections to an era of chronic disease heightened awareness of the impact of lifestyle and the environment on the great majority of early, preventable deaths and disabling illnesses and injuries. Large-scale epidemiological studies established the risk factors for cardiovascular disease and provided the scientific foundation on which to build a new national prevention strategy. The pendulum swing in the 1970s and 1980s to a conservative mood in the United States and the downturn in the economy constrained program designers to frame preventive strategies more in terms of individual behavior, lifestyle, and choice rather than to emphasize larger changes needed in the social and physical environment. Even though health protection objectives remained on the official policy agenda, educating the public to assume greater personal responsibility for health topped the list of goals. In pursuit of this goal, public health experts looked to the commercial sector for insights on how to craft effective marketing and communication programs. In the marketing realm, a major conceptual shift had started earlier. A much-quoted 1952 paper by G.D. Wiebe posed the provocative question, Why can’t brotherhood be sold like soap? Wiebe analyzed four social campaigns and concluded that a society’s aspirations can, in fact, be sold through the judicious application of marketing techniques. This paved the way for a gradual expansion of the marketer’s domain. Conceptually, marketing is rooted in exchange theory, so attention to quid pro quo-what benefit consumers can expect in return for the cost they are willing to incur-is bedrock for a marketer. Early in marketing history, the exchange process was viewed narrowly: a strictly economic exchange of some payment for some tangible product. As American marketing developed increasingly specialized and sophisticated techniques for creating and competing in differentiated mass markets, the marketing function in industry was broadened from a technical business-product orientation to a broader social process whose essential task was to identify and meet the psychological and social needs and wants of a sovereign consumer, newly moved to center stage. These changes in marketing philosophy inspired new ways of conceptualizing the role of marketing. The term social marketing was coined in 1971 by Philip Kotler, a professor of management at Northwestern University, who continues as one of the field’s leading proponents and practitioners. In 1971 Kotler and Gerald Zaltman further defined social on O cber 3, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom SOCIAL MARKETING 107 marketing as the “design, implementation, and control of programs calculated to influence the acceptability of social ideas, and involving considerations of product, planning, pricing, communication, distribution and marketing research.” The assumption behind social marketing was, and is, that well-honed and demonstrably effective techniques from the commercial business sector can successfully and efficiently be applied to advance social causes. The techniques, in a nutshell, were marketing analysis, planning, and control. They included functions such as market research, product positioning and conception, pricing, physical distribution, advertising, and promotion (hence the mnemonic “four P’s”–product, price, place, and promotion). The “social product” might be a consumable object (such as a contraceptive device), a practice (a one-time act or a more complex behavioral repertoire), or even an abstract belief, attitude, or value (like social justice). In 1981 Seymour Fine further refined the notion of producers and consumers of intangible products. Three years later the American Marketing Association created a niche for social marketing in the mainstream of marketing thought by expanding its more than twenty-five-year-old definition of marketing to include the promotion of “ideas.” Marketing Health: Early Programs Social marketing opened new areas for marketers’ expertise and intrigued public health advocates. Not only did it provide powerful new tools, but it had a kind of poetic justice in borrowing from marketers the very discipline that was aggressively promoting such harmful products as cigarettes, alcohol, fast cars, fast food, and infant formula, against which public health educators felt they were fighting a rear-guard action. Early health applications of social marketing emerged as part of the international development effort (under the banner of “development communication”) and were implemented in the third world during the 1960s and 1970s. Programs promoting immunization, family planning, various agricultural reforms, and nutrition were conducted in numerous countries in Africa, Asia, and South America during the 1970s. These built on some of the experiences of agricultural development supported by the U.S. Agency for International Development (USAID), as well as on the community-based family planning programs initiated by the Ford Foundation and the Population Council in the late 1960s out of frustration with the slow diffusion of clinically based family planning services. International programs soon began to incorporate marketing techniques, including radio, mass media, and advertising, on a wide scale. Family planning program designers, for example, initially began to break out of on O cber 3, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom 108 HEALTH AFFAIRS | Summer 1993 their clinical mold to experiment with distributing contraceptives through pharmacies and small shops, and ultimately evolved systems of market segmentation, mass communication, and product placement to accomplish wider and more efficient distribution of subsidized contraceptives. The first nationwide contraceptive social marketing program, the Nirodh condom project in India, began in 1967 with funding from the Ford Foundation. USAID increased its funding of contraceptive social marketing projects in the 1970s, supporting projects in Kenya, Colombia, Sri Lanka, and Jamaica. In fact, much of the important research and development done to advance social marketing applications to health has taken place in the international family planning field. The child survival movement has become a new center of gravity for USAID-funded international social marketing of oral rehydration products to combat the effects of diarrhea. Efforts to reduce cardiovascular disease risk also began to adapt elements of social marketing in another sphere. This trend was evident in the North Karelia, Finland, community-based heart disease prevention program, initiated in the early 1970s; in the National Heart, Lung, and Blood Institute (NHLBI)-sponsored national campaigns to reduce levels first of hypertension and then of cholesterol; and in the several generations of communitybased heart disease prevention programs sponsored by the NHLBI. Some of these programs used the term social marketing and overtly set out to apply and adapt technology from the business sector, while others borrowed a few marketing concepts or approaches without fully embracing the language and ethos of marketing. In addition, numerous smoking cessation and prevention programs over the past two decades have experimented with applications of marketing techniques; substance abuse specialists have incorporated elements of social marketing and public relations more recently in community prevention programs. The Center for Substance Abuse Prevention conducts training workshops on social marketing and health communication. Other federal government agencies, notably the National Cancer Institute (NCI) through its Office of Cancer Communications, also have been actively involved in advancing the practice of social marketing. Essential Elements Of Social Marketing Among specialists in social marketing, definitions and disciplinary boundaries seem relatively clear and straightforward, even if the techniques are not always easy to implement in the field. However, in the health literature the concept of social marketing is still elastic and elusive. Often social marketing is used synonymously with advertising or mass media campaigns seeking to shape attitudes, increase awareness, and encourage either on O cber 3, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom SOCIAL MARKETING 109 the use of certain services or changes in personal or collective behavior. Social marketers are adamant that their discipline encompasses much more than mass communication, advertising, and public affairs, although such activities are among its important components. Social marketing had its roots, they say, in social advertising and a focus on messages but has since grown in several directions. The first expansion, called social communication, broadened the focus from just the message content to promotion through channels including personal selling, publicity, and promotional events. The expansion to social marketing added market research, attention to product development, and the use of incentives and other techniques to facilitate voluntary exchange. In some quarters social marketing is being expanded to social mobilization, a term used by the United Nations International Children’s Emergency Fund (UNICEF) to connote a comprehensive planning approach stressing political coalition building and community action. Some critics of social marketing pose as an alternative media advocacy to shape public opinion and agitate for social change through strategic work at the grass roots and with those who control the communications media. The sine qua non for social marketing is rigorous up-front planning and research, with engineering-style decision-making processes. Three broad conceptual principles appear in virtually all descriptions of social marketing and can be considered an irreducible minimum: (1) The process is disciplined. Objectives are clearly stated. A variety of research and management techniques are applied to achieve identified goals, which often but not always include the mass media. A systematic tracking process monitors progress and guides midcourse corrections. (2) The consumer is heard. Target audiences are segmented along several dimensions (demographics, “psychographics,” and “mediagraphics”). This formative research goes beyond using traditional epidemiological data; it adds measures of values, images, aspirations, and concerns of potential clients. Qualitative and quantitative data collection techniques are used to develop an in-depth profile of what reaches and motivates targeted subgroups. (3) The product is responsive, based on iterative research into consumers’ wants and needs. Consumers’ responses are solicited repeatedly for continuous refinement of the fit between product positionings and market reactions. Beyond these basic objectives, a well-developed series of activities constitute the disciplined process of social marketing, as advanced in numerous textbooks and handbooks. Philip Kotler, Richard Manoff, Seymour Fine, William Novelli, Craig Lefebvre, and June Flora have been leaders in codifying these procedures for application to health. Exhibit 1 presents an amalgamation of their ideas: a sequence of nine elements that together form the basis for a comprehensive social marketing program. on O cber 3, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom 110 HEALTH AFFAIRS | Summer 1993 Exhibit 1 Description Of Social Marketine Process Elements Social marketing process elements Description of activities Phase I: Research and planning Planning Specify realistic and measurable objectives Establish checkpoints for making go/no-go decisions Review existing research and map out a program prototype Select outcomes measures to judge progress and success Consumer analysis Conduct and analyze qualitative and/ or quantitative consumer research Identify population segments of interest for whom the program may be most effective Study consumer motivational and resistance points Market analysis Designate the marketing mix (product, price, place, and promotion) Examine the fit between the chosen target group and the current product Analyze the market environment to identify competitors and allies Channel analysis Examine communication channels to determine which are best suited for reaching the target audience and achieving program goals Assess available vehicles to distribute the product Consider which organizations or institutions might collaborate Phase II: Strategy design Development of marketing mix strategy Translate the marketing mix into a program strategy by developing the product, generating methods of reducing the price (or increasing the benefits), selecting the place or system of distribution, and specifying the means of promotion Test the concepts and product prototypes with the target group Market test the strategy in a circumscribed area and refine as needed Communication Clarify ideas and information and develop pilot messages Test concepts and message strategies with the target group and rehne Produce communication materials, testing and refining them as needed Phase III: Implementation and evaluation Implementation Enlist collaborators, clarifying the nature of their involvement and securing their commitment Train key players in executing the program and in product/ service delivery Process evaluation Activate communication and distribution Assess quality of target group exposure to program communications Evaluate the delivev of the product or service Obtain data on use of the product (reasons for using/not using) Modify the product offerings or distribution and communication systems in response to consumer feedback Outcome evaluation Consider threats to the validity of research methodology and the degree to which the program assessment conforms to rigorous program evaluation design Assess program impact through statistical comparisons using preselected outcome measures Estimate cost-effectiveness of moeram on O cber 3, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom SOCIAL MARKETING 111 The field is diverse enough that few health-related social marketing programs include all of the elements. Some practitioners specialize in one or another of them. Many argue that they need the flexibility to tailor their emphasis on particular steps in the process to the demands of a specific application. But the list of process elements can be used as a template against which to gauge how complete a given program’s marketing framework is and to scrutinize the process in greater detail. Rules Of Thumb And Lessons Learned Social marketing has directly or indirectly influenced a variety of public health programs. From the literature and from our interviews, a number of generalizations and cross-cutting themes can be drawn. Research and planning. Persistence and a long time frame are essential. Lessons from cardiovascular risk reduction programs suggest that it may take up to ten years for the effective diffusion of new ideas and practices to produce measurable and consequential social change. Many of the international family planning efforts have been supported over decades, with demonstrably cost-effective results. The high profile of the Partnership for a Drug-Free America, first started in 1986, reflects a sustained, focused effort through which an annual operating budget of $3.1 million has been leveraged to yield annual investments of $362 million in donated media placements and over $50 million in volunteer creative production value. The national antismoking campaign has been ongoing, with committed efforts on the part of numerous publicand private-sector organizations, for more than thirty years. Threeto-five-year funding cycles for research and demonstration projects often support the mistaken impression that nothing ever works. Greater funding flexibility and a longer time commitment may be prereq uisites for a successful social marketing approach, especially one that addresses complex behavior patterns. A serious formative evaluation process assumes a longer front-end planning horizon than is usually built into public health programs. The possibility of midcourse adjustments and the demands of in-depth audience segmentation and analysis require greater fluidity in planning than is the rule. Funders and developers of health interventions are unaccustomed to adhering to strict decision rules, which may lead, after a period of formative research and pretesting, to fundamental changes in a program’s design or even to its abandonment. Segmentation of the audience is a critical task. While some sort of segmentation is commonly cited as an ingredient of most successful programs, typically it is done less well in public health than in marketing. Michael Slater and June Flora are developing “health lifestyle clusters” that are an on O cber 3, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom 112 HEALTH AFFAIRS | Summer 1993 interesting exception. What the marketing sciences do well is to identify, tap, and amplify the underlying values and systems that motivate potential consumers. Formal segmentation studies begin with geographic and demographic slices not very different from those familiar to program planners in health. But they go on to collect data (through focus groups, interviews, and surveys) with which to classify potential consumers on psychographic variables (lifestyle and personality factors) and attitudinal or behavioral variables. The latter are often defined in terms of responses to the type of product in question: beliefs and attitudes about it; stage of readiness to adopt it; when, why, how, and how often competitive products are being used to meet comparable needs; and what these patterns suggest about the potential market niche of the product in question. Health programs could benefit from more diversified and customized segmentation strategies, taking account of variables-such as life stage, propensity for sensation seeking, interest in changing lifestyle, and entertainment and leisure-time activities-that may be especially germane to health. Understanding target groups is a key program strategy . For each important market segment identified, formative research techniques are advocated to ascertain what moves these people, what they want for their health, and what gets in their way. This means mapping the territories in which potential consumers live-their physical, cultural, and media environments; how they spend their days; and what messages capture their attention, when, why, and with what effect. This front-end formative research should in theory enrich the design of health programs. The rigor and extent of consumer research vary greatly in practice across social marketing programs in health. Many published reports allude to formative research, but very few provide documentation or details of the results. The writings of John Worden, Lewis Donohew, and Karl Bauman and their colleagues are important exceptions; they open a window onto the potential utility for health programs of formative consumer research. Strategy design. Incentives foster motivation for all participants. Marketing and advertising experts firmly believe in incentives to motivate consumers’ behavior. Further, some stress the importance of incentives to motivate not only the individual targets for change but also potential supporters. The oral rehydration projects in Honduras and Egypt, the Stanford Three-Community Study, and “Beautiful Babies Right from the Start,” an infant mortality reduction campaign first launched in Washington, D.C., all shaped incentives for program partners (for example, distributors, media gatekeepers, third-party payers, employers, community leaders, grass-roots organizations, family members, and teachers) to contribute to on O cber 3, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom SOCIAL MARKETING 113 the success of the campaign. Teaching consumer skills supports behavior change. The success of a public health program often hinges on whether potential consumers have the skills and experience to use it. A related precept of marketing is to accept full responsibility for the customer’s satisfaction with the product and not to take for granted that the customer will have the ability, knowledge, and skills to put the product to effective use. The North Karelia program and several community-based substance abuse projects in the United States have emphasized the importance of teaching skills and enhancing efficacy. Community members in North Karelia were trained in skills related to personal health enhancement and also in skills for social action to encourage health-directed environmental change. The Midwestern Prevention Project used role playing to train adolescents in skills to resist peer pressure and trained community leaders, parents, and media gatekeepers to organize effectively against drug abuse. Malleable products are crucial for consumer satisfaction. A “product line” that supports a set of health promotion goals is sometimes cited as an ingredient of successful social marketing efforts. The Stanford group, for example, has developed an extensive line of educational materials to give their programs unity, visibility, and coherence in the consumer’s mind. The most striking characteristic of many successful international social marketing efforts has been the development of a salient, recognizable product. Attending closely to product design requires creating structured opportunities for dialogue between the health experts and targeted consumers. This is accomplished by building in pilot tests at frequent junctures in the planning process. Positionings (attempts to capture a distinctive image and niche), products, and messages are pretested, redesigned, and tested again. Consumers are engaged directly in considering the practical benefits and costs of the proposed product or service, whether reckoned in monetary terms or in more intangible but no less real psychological or social costs. Implementation and evaluation. Program success requires leadership support. A visible imprimatur from national and local decisionmakers, political figures, and opinion leaders can be crucial to a social marketing program’s success. The role in the antismoking campaign of former U.S. Surgeon General C. Everett Koop is an obvious case in point. Local political and opinion leaders can also be instrumental in creating an atmosphere conducive to change. Both the Pawtucket Heart Health Program and the Midwestern Prevention Project cite high-level leadership support as one factor contributing to success. Community participation builds local awareness and ownership. Several of the community-based cardiovascular disease prevention programs have emphasized the importance of fostering a sense of local ownership of the on O cber 3, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom 114 HEALTH AFFAIRS | Summer 1993 program. The expectation that social marketing programs will become involved in orchestrating broad-based stakeholder support clearly distinguishes them from social advertising alone and moves them closer to community organizing or community development initiatives. Integration of feedback improves program effectiveness. Much emphasis is placed in the social marketing literature on formative evaluation and rapid input of the results at each stage of a program’s evolution. Tracking systems are described by a number of programs-the Partnership for a Drug-Free America, the Stanford and Pawtucket studies, and Brazil’s breast-feeding program. Inexpensive, small, random-sample telephone surveys (called “snoops” by one member of the Stanford group) and simple questionnaires at program events gauge progress and ferret out correctable problems. Tracking systems produce data on how successful the program has been in meeting its scheduled process objectives, together with information on consumers’ experience and satisfaction with the product, service, or message and its dissemination. These data drive a process of systematic and regular feedback to guide interim corrections, tactical changes, and sometimes major rerouting of strategic direction. Limitations And Caveats Many lessons from social marketing reinforce or refocus the repertoire of standard public health practice. In one sense, social marketing is a fresh perspective that challenges health strategists to pay more attention to the consumer and to create a more responsive product. In another sense, social marketing is a structured process, which challenges health strategists to husband more resources, time, and creative ingenuity for the crucial early stages of program conception and design. In no sense is social marketing a panacea for public health. At least three powerful tensions remain unresolved: between theory and practice; between “research to know” and “research to show,” as one practitioner stated it; and between market and social values in American life. Theory versus practice. It is axiomatic in academic research that interventions rooted in theory and subjected to rigorous tests are better able than atheoretical interventions to demonstrate an effect and are also described and disseminated more persuasively. The logic behind them is clear. Without an adequate theoretical model, it is unclear what sort of failure has occurred when a program falls short of expectations: a theory failure (the idea was given a fair test and was wanting), a program failure (the idea, never implemented adequately, was neither discredited nor shown to be effective), or a research failure (problems inherent in the research confounded the test of the theory and the program). on O cber 3, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom SOCIAL MARKETING 115 Theoretical models for communication campaigns-one element of social marketing-have been well specified in a substantial body of social psychology research. It extends back before World War II and has been painstakingly synthesized and codified by William McGuire, Everett Rogers, and Brian Flay, among others. Even within this circumscribed range of social marketing practice (limited to the last of the I’s, promotion), much more remains unknown than empirically verified, as the leading theorists point out. It is often granted that social marketing programs that can apply and extend social and behavioral science theory are badly needed if we are to develop generalizable lessons and close the gap between academia and the world of action. In practice, however, the gap is dauntingly wide. Professional social marketers tend to be broadly eclectic and intuitive tinkerers in their use of available theory. Their commitment to a flexible process makes them impatient with the proposition that their craft warrants or can fruitfully be subjected to formal theory testing, a perspective captured by Richard Manoff, a pioneer in the field: “The social marketer believes that experience, not theory, offers the most useful instruction, that each effort deepens our understanding of how to make the next one better.” Some of the large, well-funded community intervention trials-Stanford leading the wayare advancing and testing elements of communication theory. But much of social marketing practice is and likely will remain as much art as science. Research to know versus research to show. Research to know is formative research, done early and incorporated immediately into program design; research to show is summative research, completed much later, to ascertain the outcomes and impacts of the investment for funding sources and others. At issue is a clash of worldviews and professional identities. The very essence of social marketing is to adapt and change, whereas summative evaluation researchers need a program to stay its course. Many small-scale, quasi-experimental studies have been done on media campaigns and marketing programs that targeted particular health beliefs, attitudes, or behavior patterns. Few have had the resources and the staying power essential for long-term summative research. Major exceptions are the Stanford five-city projects; the Pawtucket, Minnesota, and North Karelia cardiovascular risk reduction programs; several NCI-funded smoking prevention projects; and several of the family planning, oral rehydration, and nutrition education projects in developing countries. These studies have provided evidence of the effectiveness of one or more elements of social marketing applied under special conditions. However, if (as seems reasonable) the question for funders and program designers is whether and under what conditions socially marketed health interventions produce superior results and are more efficient and effective than common on O cber 3, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom 116 HEALTH AFFAIRS | Summer 1993 alternatives, almost no useful information is available to answer it. We found no studies that compared a social marketing product or program with a health program developed conventionally. Such a study would directly address the question of the marginal utility of the social marketing approach itself. Ideally, it would include a no-intervention comparison group and two treatment conditions-one a standard treatment (an orthodox or existing health service or product), the other developed through a systematic sequence of social marketing steps. In the absence of such comparative research, the case for social marketing rests on the track record of marketing itself (a well-established management science), the perceptions of practitioners who have applied the techniques to health products and programs, and the argument that a health or social program whose design includes a disciplined assessment of the culture, beliefs, attitudes, patterns of communication, and constraints operating within specific target groups ought to be more effective than one that ignores those considerations or addresses them only superficially. Market versus social values. Commercial marketing rests, ultimately, on a market test. It favors principles of efficiency. Formative research, conducted before a campaign is launched, probes whether the target population is receptive to the product or idea. If not, the launch is scrubbed. Much effort is spent in seeking to identify an issue about which public attention and concern are already heightened; thus, success can be achieved with relatively minor shifts in attitudes and consumer behavior. How quickly success might have been achieved without social marketing is of little consequence to the marketer. The collection of adequate baseline data needed to isolate the contribution of a particular input to the general momentum of a project would be a diversion of resources that could be spent better in formative research and product design. A commercial marketer can do very well by shifting a large market one or two percentage points, whereas health promotion objectives generally seek behavioral shifts of 20 or 30 percent or more across a population at risk. Commercial marketing, moreover, selects the easy targets, while social interventions often seek out the hard-to-reach. One widely used typology for lifestyle segmentation, SRI International’s Values and Lifestyles (VALS) framework, underscores this point. Drawing on Abraham Maslow’s notion of a hierarchy of needs, it categorizes Americans by developmental stages. Those in the bottom two strata, a “need-driven stage” (an estimated 11 percent of the population), lack the economic resources to interest marketers. By contrast, for the field of public health, faced with shrinking health resources and growing pressures generated by epidemics and desperate needs, the lower strata of the population are of urgent and mounting concern. on O cber 3, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom SOCIAL MARKETING 117 In fact, some critics of social marketing contend that a marketing orientation is fundamentally at odds with the core values of public health. Douglas Solomon, for example, suggests that “considering the negative image that commercial marketing has in many people’s minds, a social campaign designer might best avoid using the term marketing at all, and simply apply what he or she has learned from the field.” The case against social marketing, most often argued by Larry Wallack, rests on several premises. 16 The first is that social marketing emphasizes individual change strategies and deflects attention from the social and physical environment. Second, it is argued, marketing reflects commercial values and interests, fosters passivity and dependence on “experts,” and promotes consumption as a way of life. Marketing is part of the problem, not the solution. Finally, the critics assert, with all of these downside risks, the advantages for public health of marketing and media campaigns have yet to be convincingly demonstrated. Social marketing proponents counter by pointing out that the best of their programs include skill development, consumer participation, coalition building, and activism. Many argue for a broad perspective and multiple interventions in multiple markets, all oriented toward empowering people to confront and change threats to their health and well-being (including economic and social deprivation, objectionable advertising of health-compromising products, and environmental degradation). Many of the major writers on social marketing have strongly stressed ethical issues and the need for responsibility and accountability to the people being served, lest they be coerced, even if “for their own good.” Issues For The Future If public health offers to social marketing the challenge of a research and policy agenda that still needs to be addressed fully, social marketing stretches public health in at least two important directions. First, it calls attention to the need to learn how to identify fruitful areas for using social marketing strategies. Criteria are needed to diagnose and identify lowrisk/ high-yield opportunities for applying social marketing principles and techniques to pressing public health issues and for assessing readiness to change-not only of individuals, but also of organizations, institutions, and communities. This information could support public health practitioners in defining more pointed and potentially powerful strategic action plans. Second, social marketing experience to date challenges health specialists to think in new ways about consumers and product design. Entering the marketing world requires abandoning the expert’s mind-set that the product is intrinsically good, so that if it fails to sell, the defect must reside in on O cber 3, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom 118 HEALTH AFFAIRS | Summer 1993 uninformed or unmotivated consumers who need shrewder instruction or louder exhortation. A marketing approach demands attention to the cultural appropriateness, adequacy, and accessibility of initiatives as they are being designed, rather than having to retrofit them after messages promoting them have fallen on deaf ears. Marketing and advertising specialists frequently complain that they are called in late in the process to promote interventions that were fatally flawed from their initial conception. Unresolved issues do remain. Definitions of social marketing are more than semantic exercises when a too-facile use of the jargon makes a program sound more structured or participatory than it actually has been. Nor is an expert-driven study of the psychology of clients or consumers the same as increasing their active participation in program design. Furthermore, although advertising is usually couched in terms of divining, crystallizing, and meeting the consumer’s latent wants and needs, the reality is that truly great marketing creates needs and opens new markets. Concerns about the commercialization of American life and about the murky boundaries between persuasion and manipulation cannot be brushed aside in a full appraisal of the costs and benefits of a marketing approach to health. Still, the advent of social marketing comes at an auspicious time for public health. A shift has been taking place away from an exclusive emphasis on individual causation and responsibility for disease toward a focus on community empowerment. Many intervention models are being developed that emphasize structural or systems-level variables, not just those at the individual level. At the same time, the importance of ethnicity and multiculturalism is increasingly being recognized. Health practitioners are looking for tools and techniques that will enable them to understand their clients’ social worlds and the range of social forces that shape their activities. Social marketing is developing “sense-making” techniques to convert communication from a process of transmission to a process of dialogue, something health educators are increasingly eager to do. As a result, a social marketing perspective on health raises the possibility that a number of the perennially frustrating health problems society continues to confront-the inadequate reach of prenatal care, immunization, and other public health services; and the intractability of risk behavior leading to the spread of human immunodeficiency virus, substance abuse, teenage pregnancy, and violent injury-can be radically rethought and more effectively addressed. The disciplined up-front technology of market analysis and formative research could help to facilitate this critical review, the object of which would be to isolate those approaches that really do enable individuals and communities to gain greater control over their health and the quality of their lives. on O cber 3, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom SOCIAL MARKETING 119 This work was supported by a grant from The Commonwealth Fund. The authors thank Penny Duckham and Mary Lou Russell for insightful comments and assistance, and Robert Blendon, William DeJong, Beverly Freedman, Stephen Harty , Christine Hollis, Valerie Knight-Williams, Steven Rabin, Tony Schwartz, Glenn Wasek, and Jay Winsten for contributions to the research.