Global context

Changing patterns of food production, distribution, marketing and consumption and declining physical activity levels in many parts of the developing world are driving the global trend of weight gain⁽Reference Popkin^1–Reference James³⁾. Overweight and obesity affects more than half the adult population in the developed world, and is now more prevalent in the developing world than chronic undernutrition⁽⁴⁾. Furthermore, prevalence is increasing overall at a faster rate in developing economies than in developed economies. In Mexico, for example, obesity prevalence is accelerating faster than anywhere in the world, leading to 28·1% of females and 18·6% of males >15 years of age classified as obese in 2006⁽⁴⁾. Alongside the trend towards excess weight gain are multiple changes in nutrition quality of the diet, some contributing positively, and some negatively, to epidemiological trends. Complex starchy carbohydrates are being replaced with more protein, more total and saturated fats and more refined simple carbohydrates and sugars⁽Reference James^3, Reference Astrup, Dyerberg and Selleck⁵⁾. These dietary changes, along with changes in consumer perceptions of food, food consumption norms and body image, commonly described as a nutritional transition, often co-exist with continued undernutrition (particularly micronutrient deficiencies). In many instances this double burden of malnutrition can be found in the same household⁽Reference Popkin¹⁾ and raises unique public health and communication challenges.

The growing evidence base on the key factors contributing to patterns of ‘globesity’ in nutritional transition countries and those in the developed world is contributing to the convergence in thinking internationally on causal factors. This process in turn is generating promising insights into more effective preventive measures against excess weight gain.

The recently-completed Foresight review of obesity and overweight in the UK⁽Reference Butland, Jebb and Kopelman^6–Reference Brown, Kelly and Summerbell⁸⁾ provides a very comprehensive and thorough summary of current understanding. A culture that promotes energy-dense foods and increasingly sedentary lifestyles, combined with a biological predisposition towards modest overconsumption of energy is creating an emerging norm of excess weight gain and metabolic abnormalities. The drivers are systems-wide and influential throughout the life cycle. Thus, strategies that promote and support healthy weight management must also be consistent with, and relevant to, a broad range of circumstances and unique nutritional needs. This task is huge and requires the engagement and resources of many stakeholders. The goals include enabling and incentivising individual choice, supporting with appropriate information and policy controls, and shifting the distribution curve for body weight and activity levels towards more healthful norms.

The challenge of how this objective can be achieved at a population level, sustainably and equitably, is most definitely still considered a work in progress⁽Reference Jebb, Kopelman and Butland⁷⁾.

The evolving nature of social marketing

Social marketing can offer insights into many of the inter-related constituent parts of what has come to be known as the ‘obesogenic environment’: it offers a unique approach to understanding interpersonal factors that influence pre-existing behaviour patterns and which of these factors may be responsive to behavioural change levers. Most crucially, social marketing research is rooted in the pragmatic aim of generating insights into bridging the intention–behaviour gap⁽Reference Prendergast, Foley and Menne⁹⁾.

Social marketing has its origins in efforts to deliver public health interventions to resource-poor communities and individuals in the developing world. A core principle of early social marketing initiatives was the leveraging of both the logistic and engagement expertise of the commercial sector to achieve key public health goals⁽Reference Walsh, Rudd and Moeykens^10–Reference Brown¹²⁾. Social marketing cut its teeth developing strategies and techniques that influenced both the supply and demand side. The marketing efforts for products such as barrier contraceptives and hand soap, as well as services such as immunisation, were designed to improve awareness of their benefits, increase real and perceived accessibility and most crucially enable and promote voluntary behaviour change. Soon afterwards, the infant concept of social marketing began taking steps in the direction of behaviour change independent of any associated products or services.

The potential of the social marketing prodigy to bring about behaviour change purely through the use of marketing techniques and thinking began to be recognised. This recognition was not, and is not, a blinding light of revelation. The emerging marketing skill set for behaviour change is based on a growing understanding of the power of marketing to bring about voluntary behaviour change. Marketing uses client-focused research techniques such as segmentation of target groups. Segmentation concentrates on identifying which groups of interpersonal and external factors are most influential (positively or negatively) in behavioural change. For example, these factors may include aspirational values, real-life behaviours and real or perceived barriers to change. These findings may have little obvious link to fundamental health objectives such as reducing fat content of the diet, but do provide the mechanism to facilitate desired change by linking to lifestyle choices of broad groupings of individuals. Marketing methods then use this knowledge to develop and refine genuine exchange of benefits ‘offers’ to the target groups. The principle of exchange is critical to the success of marketing and is based on the recognition that any voluntary change incurs costs (such as inconvenience, uncertainty of outcome), is optional and must therefore offer valued benefits (e.g. immediate outcomes not long-term risk reduction). Table 1 provides a summary of key characteristics of social marketing principles, as defined by Andreasen⁽Reference Andreasen¹³⁾.

Table 1. Benchmarking criteria for social marketing (adapted from Andreasen⁽Reference Andreasen¹³⁾)

Social marketing researchers and practitioners are not only honing skills in the use of their own tool box. They are also finding where these tools fit in, complement or indeed challenge the approaches and methods used by their more traditional public health peers and colleagues (and indeed other social sectors concerned with behaviour change). For example, a description has been given of the use of the social marketing and response tool to position and adapt diabetes interventions to be more effective in reaching, and being adopted by, ethnic minority groups than ‘more traditional top down approaches’⁽Reference Thackeray and Neiger¹⁴⁾. Interventions that last from 12 weeks to 1 year have achieved better clinical outcomes, improved knowledge levels and positive dietary change by investing in preliminary social marketing research, culturally-sensitive modification of programmes (psycho-demographic segmentation) and further development informed by audience-focused evaluation.

As social marketing continues to forge early career paths in fields such as public health, an extent of experimentation and reflection is both necessary and desirable. Social marketing is best understood as a pragmatic framework for understanding how and why individuals make lifestyle choices (that result in unintended as well as intended consequences) and for devising and marketing desirable alternatives. Good-quality social marketing is theory based and goal driven, but also critically reflective, seeking creative insight from multiple disciplines including psychology, sociology, communications, behavioural economics, business and commerce⁽Reference Prendergast, Foley and Menne^9, Reference Lefebvre, Bloom and Gundlach¹⁵⁾.

The pragmatic and multi-disciplinary approach of social marketing fits well with the current demand for new thinking and responses to the complex multi-factorial global trend of excess weight gain and associated ill health and disease.

Better understanding of how and why overweight and obesity have become the most prevalent form of malnutrition in the world can both learn from, and inform, social marketing as an evolving paradigm for behaviour change.

Competitive analysis and effective responses

Enabling and bringing about voluntary behaviour change is the core objective of social marketing. To be effective social marketing, like commercial marketing, must start by understanding the competition. Competition may come in many guises: commercial marketing activities; perceptions of the expectations of influential others; other demands on time and resources encouraging maintenance of existing behaviour patterns (the status quo). These factors are all examples of what may be influential competition to desirable behaviour change.

Commercial marketing activities may be benign, even beneficial, presenting consumers with greater choice and novel routes to healthful lifestyle choices. Conversely, choices available may create subtle but powerful barriers to change through their influence on awareness, motivation and environmental infrastructure. Low priced well-targeted promotion of, and ready availability of, energy-dense and/or low-satiating-power foods is an example of competition against more healthful choices. Geographic studies have found higher density of quick-service restaurants in less-affluent neighbourhoods⁽Reference Macdonald, Cummins and Macintyre¹⁶⁾. This area of research provides interesting examples of how commercial marketing practices make less healthful food choices so easy that they become almost ‘monopolistic’ for those with restricted purchase options such as lack of transport and tight budgets. A further illustration of this kind of competitive analysis is the 2003 Hastings Report, a systematic evidence review of the effect of food promotion targeting children⁽Reference Hastings, Stead and McDermott¹⁷⁾. The review finds that the content of food promotion focuses heavily on foods that do not fit with recommended dietary guidelines and is adversely influential in children's food health perceptions and preferences.

The evidence generated from critical analysis of market forces may indicate that competitive forces are so powerful that policy change is required to enable large-scale behavioural change to occur. Just as social marketing research has been highly influential in providing the evidence base for policy change on tobacco marketing, analysis of the commercial influences on consumers' diet and weight-management perceptions and behaviours may provide evidence for appropriate obesity control policy⁽Reference Butland, Jebb and Kopelman^6, Reference Brown, Kelly and Summerbell^8, Reference Hastings, Stead and McDermott¹⁷⁾.

Alternatively, analysis of the impact of commercial marketing influences may generate evidence for alternatives to legislative intervention. For example, understanding the reasons for the success of commercial marketing of food and beverages can inform and guide more effective counter-marketing strategies. Research on consumer response to commercial marketing can provide insights on how to most effectively shift perceptions (such as cool, fun, convenient) around desirable but less-healthful foods and food groups. Commercially-focused market research such as the LifeChoices survey⁽Reference Nielsen¹⁸⁾, which examines the relationship between heuristic decisions about out-of-home eating and drinking choices and weight management concerns, bring an alternative perspective on consumer priorities to more academic research methodologies. Such research highlights consumer preferences for food choices that save time, meet social needs and fit with existing taste preferences and expectations.

Engaging the multiple agents of change

Social marketing also seeks to change the behaviour across the broad stakeholder base, e.g. public health and education professionals, parents, peer groups and of course mass media. The rationale for this approach is rooted in social cognitive theory, which recognises interaction of the internal environment and interpersonal influencers on behaviour choice. For example, the Walk to School campaign provides the stimulus for schools and parents to create safer easier opportunities for children to walk or cycle to school and increase levels of physical activity⁽Reference Living¹⁹⁾.

Message intermediaries such as the media can be highly influential in moderating perceptions of norms and values. Media messages and themes may reinforce existing behaviours and perceptions (e.g. it is not safe for children to walk to school) or become part of the impetus for change (e.g. walking to school is not only safer than using the car, but educationally, socially and physically beneficial for children)⁽Reference Living¹⁹⁾.

Trust is recognised in innovation diffusion theory as an essential component of the behaviour change process⁽Reference Crawford and Ball^20, Reference Oldenberg, Hardcastle, Kok, Glanz, Lewis and Rimer²¹⁾. Change is risky, unpredictable and inconvenient; in general, requiring individuals to temporarily step outside their ‘comfort zone’. Tools and strategies that reduce sense of unease and discomfort are therefore very valuable. Campaigns and organisations that are successful and establish trust not only achieve their immediate objectives but also establish brand value⁽Reference Evans and Hastings²²⁾.

Brand value is one of the most powerful tools of the marketing tool box. An established brand is a hugely influential symbol encouraging both repeat behaviour (in the commercial world, for example, repeat purchase) and new behaviour (e.g. a willingness to buy and try a new commercial product). As long as the brand continues to deliver on perceived promises, it conveys and reinforces commitment, a sense of relationship, and is interpreted as a guarantee to deliver a bundle of values. Conversely, poor brand image or a brand image that does not fit with perception of what is desirable discourages the risky business of change. For some individuals the brand image of ‘Weight Watchers’ may be more attractive than the image of NHS-based weight-reduction advice; for others, the converse. The ‘brand image’ of former US President Bill Clinton was used to great effect to promote walking and active lifestyles for better health and weight management⁽²³⁾.

Social marketing may also be used to enhance the effectiveness of the professional skills of stakeholders who seek to promote behaviour change. Social marketing techniques such as segmentation and consumer insight research framed within the diffusion of innovation theory enable resources to be targeted and customised to enhance relevance and impact by identifying key perceived barriers and motivators for broad-target adopter groups⁽Reference Crawford and Ball²⁰⁾. For example, active lifestyle campaigns based on increased uptake of community facilities may use messages focused on health benefits, delivered through healthcare services, to target those individuals with current health concerns. To reach those individuals who are currently non-users because of childcare and work commitments, personal transport or financial constraints, adaptation of the community services supported with advertising communicated through local socially-based channels may be more effective.

Delivering value to the target adopters

Segmentation, targeting, positioning and building brand value are not just valuable tools in the implementation of social marketing research and interventions, they are also useful in putting client orientation at the heart of behaviour change thinking.

Voluntary behaviour change is by definition under the control of the target adopter. Not only does the choice to try new behaviours lie with the target adopter, he or she also determine its sustainability. Diet and lifestyle choices that impact health such as weight management must be maintained for years, through the multiple stages of the life cycle and/or changes in life circumstances in order to improve health outcomes⁽Reference Butland, Jebb and Kopelman^6, Reference Brown, Kelly and Summerbell^8, Reference Swinburn and Egger^24, Reference Wardle²⁵⁾. Social marketing aims to engage and establish strong and valued relationships with the client or client groups. Social marketing recognises that productive and resilient relationships must offer something to both parties, a mutually-beneficial exchange. The concept of value exchange is perhaps the most definitive characteristic of a social marketing approach to any public health or social behavioural change issue. Social marketers recognise that behaviour change ultimately delivers benefit to the end consumer but also presents a cost⁽Reference Lefebvre, Bloom and Gundlach^15, Reference Hastings²⁶⁾.

Obvious potential tactics are minimising cost (e.g. by identifying routes to more active lifestyles and healthier diets that involve acceptable levels of disruption) and maximising delivery and communication of benefits (e.g. by highlighting immediate changes to health rather than focusing on long-term risk reduction).

Additionally, however, to be effective a social marketing approach would aim to root direct intervention within an overall strategic plan. Direct interventions are most effective when linked with weight-management influencers on multiple levels (individual, sectoral and environmental) and multiple stakeholder channels (consistent messaging, via multiple channels and engaging support of stakeholders who might otherwise inadvertently represent barriers)⁽Reference McDermott, Stead and Gordon²⁷⁾. For example, changes to school food services will be more effective if they consult and respond to students, staff and family. Food service planning might also consider how best to address local competition such as the chip van or corner shop, build brand value through local media and quality service delivery and employ a continuous cycle of feedback, adaptive response and communication (see Fig. 1).

Fig. 1. Social marketing plan. (Adapted from Hastings⁽Reference Hastings²⁶⁾.)

Similarly, programmes to encourage more active lifestyles might offer clear incremental goals, consider fiscal implications and offer flexibility with a range of uptake options. Communication of short- and long-term benefits, and starting with a needs assessment from the target audience perspective would also be recommended from a social marketing perspective.

Critical research questions from a social marketing perspective

From a client-oriented perspective, a current situation analysis raises questions such as:

1. 1. as overweight and obesity becomes more prevalent than healthy weight, how does this trend contribute to perceptions and tolerance of unhealthy body weight as the norm;

2. 2. who are the key stakeholders from a professional perspective, and who or what are key opinion leaders, motivators and barriers to change from a layperson perspective; how do these perspectives differ and what are the implications for these differences;

3. 3. what are the most effective potential and current motivators for weight control and how can they best be marketed;

4. 4. how can the most influential stakeholders become more fully engaged;

5. 5. what are the unintended consequences of obesity-focused interventions and communications, and might these factors impact on the credibility of future initiatives;

6. 6. what are the barriers, incentives or catalysts for multi-sectoral policy alignment. How can new thinking and approaches in support of behavioural change be ‘marketed’ at this sectoral level;

7. 7. what are the key criteria for measuring efficacy and progress.

Many of these questions fit well with the proposed iterative implementation and research cycle of policy action and interventions to address the current trends in overweight.