Realising that just telling people about healthy living won’t necessary make them change, the NHS is employing social marketing. Clare Lomas looks at how this idea, with its more targeted and even informal approach, can lead to people acting on public health messages
A hard-hitting video on YouTube last month appeared to show a young girl giving birth on a school playing field. For many, it made very uncomfortable viewing.
But, although the video looked like it had been filmed on a pupil’s mobile phone, it had been created by Leicester PCT to raise awareness of the issue of teenage pregnancy in the area.
In Leicester, around one in 20 girls aged 15-17 become pregnant every year, and nearly half of the city’s wards are defined by the PCT as teenage pregnancy ‘hot spots’.
The short clip, dubbed Teenage Kicks, forms part of a social marketing campaign by Leicester City Teenage Pregnancy and Parenthood Partnership, part of NHS Leicester City, to tackle the growing problem of teenage pregnancy and raise awareness of safe sex among young people.
Alongside the video, the PCT launched a website – www.hey-babe.co.uk – providing information and education on sex, pregnancy and relationships. The website also includes a contacts section where young people can find contraceptive services in the area.
According to a spokesperson for NHS Leicester City, the package of a video, website and docu-drama – which included actors discussing issues around sex and relationships on the website last week – was selected because the target audience of 15–17 year olds was not receptive to traditional ‘preachy’ public health type messages.
‘The campaign was based on what young people in Leicester told us they wanted to know,’ said Tim Rideout, NHS Leicester City’s chief executive.
‘Leaflets and posters were not getting their attention, and those who don’t attend or have left school are missing out on sex education in schools.
‘Ongoing initiatives from Leicester City’s Teenage Pregnancy and Parenthood Partnership have contributed to a reduction in the teenage pregnancy rate but, to make a long-term impact on the upward trend, this type of campaign is essential,’ he added.
Using social marketing techniques to tackle health inequalities and attempt to get public health messages across more effectively is becoming increasingly common in the NHS.
What sets the idea apart from traditional public health information campaigns is that, as well as attempting to raise awareness about an issue, social marketing projects provide people with the tools to enable them to change their behaviours.
‘It is more than just a message. Its main aim is to change behaviours, not just to raise awareness or shift attitudes’
Lucy Reynolds, NSMC project manager
‘Social marketing is about creating products and services that support people to change their behaviours,’ said Lucy Reynolds, project manager at the National Social Marketing Centre (NSMC), which was set up in 2006 as a joint partnership between the Department of Health and Consumer Focus, formerly the National Consumer Council.
‘It aims to understand why people behave as they do, and what might be blocking them from changing their behaviours. It then uses this information to design solutions that respond to their individual wants, aspirations and needs.’
She added: ‘But it is more than just a message. Although communications may be part of a social marketing programme, there will always be more than information giving. Its main aim is to change behaviours, not just to raise awareness or shift attitudes.’
The NSMC has set out eight national benchmark criteria for social marketing that NHS organisations can use to guide social marketing campaigns, and measure themselves against. These include developing a robust understanding of the target audience, behavioural analysis, focusing on what ‘moves and motivates’ people, and identifying an appropriate ‘mix of methods’ to achieve objectives.
Additionally, last summer saw the launch of the Department of Health’s Ambitions for Health framework. Billed as a ‘strategic framework for maximising the potential of social marketing’, it underlined the government’s commitment to putting people at the heart of its health improvement programmes.
In April this year, the NSMC also launched ShowCase, the first collection of case studies showing the positive impact that social marketing can have on health behaviour.
One of the most high-profile examples of social marketing highlighted by ShowCase is the Department of Health’s alcohol social marketing strategy. Launched in May 2007, the campaign was designed to tackle the growing number of people admitted to hospital with alcohol-related problems, and make people aware of how much they are drinking.
The Know Your Limits campaign used a mixture of methods, including TV adverts and posters, to raise awareness of the number of units it is safe to drink.
‘Finding new ways to motivate people to lead healthier lives is vital to making improvements in public health’
Department of Health
As part of the campaign, the DH developed a DrinkCheck website. Based on the World Health Organization’s AUDIT test, this guided users through a questionnaire which then indicated their level of risk and gave them the opportunity to order the Your Drinking & You booklet, which is designed to assist people to cut down.
The DH also ran a telephone helpline service, distributed fact sheets, wall charts and handouts to GPs about the dangers of harmful drinking, and provided tools to help healthcare professionals identify people who may be drinking to harmful or hazardous levels.
A DH spokesperson told Nursing Times: ‘Research suggests that 86% of people think that the government should intervene to prevent illness by providing information and advice, but 89% of people think individuals are responsible for their own health. This proves the need to find new ways of empowering people to make the choices themselves.
‘Social marketing is rooted in a deep understanding of what people think and how they act, and can be a powerful tool for bringing about behavioural change. Finding new ways to motivate people to lead healthier lives is vital to making improvements in public health,’ he said.
The Department of Health’s national cleanyourhands campaign is an example of social marketing with which all nurses should be familiar. By distributing posters targeted at healthcare staff and patients, and providing alcohol handgel in all wards and other clinical areas, the campaign has contributed to the massive reduction in MRSA bacteraemias seen in recent years.
The programme uses a marketing mix to educate, prompt and enable healthcare staff to clean their hands at the right time, every time, during their care of patients. The key message of the campaign is that staff must clean their hands at the point of care.
Since its launch in September 2004, the campaign has been adopted by all acute NHS trusts in England and Wales, and government funding for cleanyourhands in acute trusts has been confirmed until the end of this year.
In April 2008, the campaign was extended to PCTs, mental health trusts and ambulance trusts. The campaign in these types of organisation is scheduled to run until 2011.
Social marketing has been equally successful at a local level. As well as the Leicester example on teenage pregnancy, social marketing techniques have been adopted locally to tackle a wide range of health issues, from cervical screening to smoking cessation – with impressive results.
In April 2008, a three-year project to improve cervical screening rates among 25–39 year old women was set up in the West Midlands. What’s Pants, But Could Save Your Life? was the first cervical screening initiative in the UK to directly link data trends, audience segmentation and social behaviour research with an awareness-raising campaign.
The project included increased service provision – including additional screening clinics – posters on buses, radio advertisements, leaflets and personalised letters. The campaign also has a website – www.pants.nhs.uk – which provides information about cervical cancer, and directs women to where they can go for cervical screening in the West Midlands area.
According to data from the project, there has been an unprecedented increase in cervical cancer screening uptake in 25–39 year olds in the West Midlands region, with the first three months of the project seeing a 16% increase in the uptake of cervical screening in this age group.
‘We have had a lot of fun with the campaign, but the underlying message is a serious one’
Karen Wade, Worcestershire PCT cervical screening lead
Karen Wade, cervical screening lead at Worcestershire PCT, who has been involved in the campaign, said: ‘Research showed a significant lack of uptake in cervical screening in the target age group in the West Midlands. We decided to use the light-hearted concept of “pants” because pants can also mean rubbish, and although it is rubbish to have to go for a smear test – it is also vital.
‘Cervical cancer affects younger women more than older women, and younger people are more receptive to a light-hearted message. We have had a lot of fun with the campaign, but the underlying message is a serious one.
‘Some areas [of the West Midlands] are also getting a lot of requests for screening from women outside the age range, and women who have not had a smear test in 10 years are now attending for screening.’
A social marketing campaign to encourage breastfeeding among 18–25 year old mothers in Lancashire has had similarly positive results. Commissioned by Central Lancashire PCT, in partnership with the Little Angels breastfeeding peer support organisation, the Be a Star campaign promotes breastfeeding among young mothers by celebrating those who breastfeed as ‘stars’.
To make breastfeeding appear glamorous and sexy, and to appeal to the target audience, young breastfeeding mothers are given makeovers to look like models, celebrities, singers and actresses.
‘Our research showed that the rates of breastfeeding among 18–25 year old mums was the lowest in the area, particularly among the lower socioeconomic groups,’ said Glenis Tansey, public health specialist at NHS Central Lancashire. ‘After consulting with health professionals and young women to find out what they wanted, we decided this was the best approach to take to target this particular group.’
Results from the project show that the number of young mums now breastfeeding in the Lancashire area has risen from 52% in March 2008 to around 63% in March 2009. The number of mums of all ages breastfeeding in the Bolton area specifically has also risen – from 65% to 82% since the campaign began.
Three of the ‘star’ mothers have been trained as peer-to-peer supporters for other young mothers. One – Laura Taylor from Preston – enrolled in a midwifery course within six months of her involvement in the programme.
The use of social marketing techniques has had a significant impact on smoking cessation. In 2006, research showed that more than one-third of people in the Knowsley area of Merseyside were current smokers.
Following a joint campaign between NHS Knowsley and the Roy Castle Lung Cancer Foundation’s FagEnds project, data from 2007–2008 showed that a higher proportion of smokers in Knowsley quit smoking than anywhere else in England.
The five-year project – set up in 2006 – used a mix of tailored support packages and drop-in cessation groups to make quitting smoking as convenient and easy as possible.
A project in Scotland to support smoking cessation in pregnant women has also seen some positive results. Launched in 2007, the Give It Up For Baby project works with mothers from socially deprived communities, paying an incentive of £12.50 per week to every woman who demonstrates she is smoke free. By the end of the first year, 55 mothers had successfully quit in Dundee, and 140 had quit in Tayside.
The concept of monetary incentives involved in social marketing projects has been the subject of some controversy. Last month, an article in The Sunday Times newspaper highlighted a number of NHS incentive schemes which ‘bribed’ people into giving up bad habits.
‘It is about understanding the people that we’re serving and making sure that services are geared around their needs’
NSMC director Professor Jeff French
Ms Reynolds acknowledged that using incentives could sometimes attract moral criticism but said it could be a powerful tool in helping people to change. ‘Social marketing is not just about giving people incentives, but incentivisation can be a key element of the methods mix,’ she said.
‘Give It Up For Baby works with “hard to reach” mothers from socially deprived communities. Research revealed an invaluable piece of insight – in a community where smoking was the social norm and quitting was frowned upon – offering financial incentives gave women a socially-acceptable reason, or excuse, for quitting,’ she said.
‘Incentives aren’t without moral issues – but they are a valuable part of the intervention mix in some cases, and can have powerful impacts on people’s behaviours.’
Although social marketing may be a relatively new concept for most nurses, adopting this more targetedapproach can make a significant difference to patient care, according to Professor Jeff French, director of the NSMC.
‘NHS professionals need to develop their skills and put more effort and investment into building up a more thorough picture of the customers, clients and patients that they’re seeking to serve,’ he said.
‘It is about understanding the people that we’re serving and making sure that services are geared around their needs – as well as what the evidence is telling us about clinical practice and delivery.’