Just before Royal Wedding bank holiday the Government published Changing Behaviour, Improving Outcomes: A new social marketing strategy for public health. It has clearly taken a little while for the national media to pick up on its contents, however some of the more significant issues it covered regarding the impact to government public health advertising campaigns did receive news coverage by this bank holiday weekend! The points that received the most attention are set out on page 28 of the report:
We have now had the opportunity to learn from the freeze and to assess where the loss of mass communications had a negative impact. For example:
- the number of people joining Change4Life fell by 80%. Calls to the Change4Life information line fell by 90% and web visits by two thirds;
- calls to the FRANK help line fell by 22% and web visits by 17%;
- visits to the Smokefree website fell by 50% The volume of people making a quit attempts also fell, in line with the reduction in purchased media spend;
- Rehab 4 Addiction offers free support and help to people who suffer with alcohol and drug addiction – Rehab 4 Addiction offers free telephone assistance and also maintains useful resources and guides on its website.
Evidence submitted to the All Party Parliamentary Group on Smoking and Health concluded that the cessation of marketing activity has resulted in declining quit attempts and subsequent loss of life from smoking-related illness.
These studies followed the criticism of the DoH decision last year to axe the £1.5m awareness campaign for flu vaccinations and the research showing the impact the withdrawal had on public take-up. This year the Government seems to be planning much earlier for any eventuality regarding flu vaccination. In response to these studies an extra £15m has now been set aside for promoting the government’s anti-smoking website and £14m will be made available for a campaign promoting healthy living. This has been generally welcomed by the social marketing community. However, the total spending is still less than half the £93m spent by the previous government in 2009/2010. However it is important to go beyond the news coverage to look at whether the new social marketing strategy is likely to provide as much bang for less bucks in terms of promoting public health. In summary its critique is as follows:
- Over-prioritisation of primary prevention (smoking, drinking at harmful levels etc.) to the near exclusion of secondary prevention (such as early detection).
- Very long timescales for payback (whereas secondary prevention might pay back sooner).
- Duplication of resource, for example via the reinvention of insights, duplication of creative assets.
- Too much top down direction and too little local creation, resulting in a lack of local knowledge and local marketers either “cherry-picking” from national initiatives or generating their own ides.
- With the exception of Change4Life, a focus on single-issue campaigns, missing the opportunity to “ladder” people up from successfully tackling one behaviour, to changing others.
- A lack of coordination across Government.
- Failure to employ all marketing levers, particularly intermediary marketing.
It says that whilst central social marketing budgets will run at 40% of 2009 spend in future, much more will be done locally after 2013. However in the meantime it says (page 22):
“While we anticipate that local areas will eventually take a leadership role in the development, implementation and funding of social marketing, it is likely that local spending on social marketing will dip during the transition period. It will be crucial to work with local areas, whether NHS or local authorities, to enable them to join up what activity they can fund with national programmes in the least resource-intensive ways possible.”
The document then sets out a new strategy:
- There will be far fewer social marketing programmes, prioritising those that are proven to work.
- With the exception of smoking, there will be no central single-issue campaigns. Instead social marketing will take a life course approach, through which a trusted brand will deliver support on all topics that are relevant to a person at that stage.
- More will be done at a local level; the centre will do only those things which it alone is best placed to do.
- Emerging insights from the behavioural sciences will be deployed to enhance existing programmes and design radically different marketing initiatives.
- Partners, including commercial sector partners, will be asked to do more.
- While some advertising is resuming, we will continue the shift away from traditional mass media channels, towards lower-cost channels and those (such as Government web sites or posters in hospitals and General Practice) that we own.
- We will increase our use of social media, to enable people to build and join networks of others who face similar problems and to access, create and share information and ideas through those networks.
- Where our campaigns enter into frequent and regular conversations with people, we will test ways of migrating these communications into lower-cost digital channels.
- We will work with the Cabinet Office to pilot a payment by results approach in appropriate areas.
There will be 4 main government national campaigns instead of the plethora of single issue campaigns
Much of the critique and new strategy makes a lot of sense. However the challenge is to deliver it as a full replacement at a time when there is such a drop in advertising demonstrably having an immediate impact on take-up of services. In the absence of resources for national advertising PCT’s working with the new Health and Well-Being Boards and GP Consortia may need to look at whether more effective use of staff conversations and existing peer to peer engagement can be developed to take up some of the load until ring-fenced local government operated public health budgets exist. The other interesting point in the report is the shift from primary to secondary prevention around the issue of early detection. The issue here is who will deliver this? Will it be the new GP Consortia? As the statistics at the start of this posting indicate, it does show that the provision of information works for some people and the reduction in the supply of this information does have an impact.However, as we have blogged before, the advertising does not reach everyone – often because it is communicated in such a way that does not reach out to the targeted individual’s own values. The Government see the advertising approach as expensive and instead seem to see diffusion of innovation theory as a relatively cheap behavioural change approach – mainly driven by private sector IT providers to show some progress – as is shown by the text on pages 29-33 of the strategy, which I set out in full below:
- Private: securely encrypted communications are passed between parties, allowing transmission of information that is sensitive.
- Personal: customised communications are sent to individuals.
- Public (social media): communications are shared in an unrestricted manner, with the express intention that others may read and share the content.
8.3.12 Social media channels also enable us to rapidly disseminate messages to our networks of supporters (for example via our Twitter feeds). 8.3.13 At its best, technology can empower citizens to make better decisions about their wellbeing for themselves (and their dependents), based on their own individual circumstances. 8.3.14 Technology also facilitates individual tailoring of information and presentation of choice based on personal circumstances. 8.3.15 Access to new technologies has grown so fast (as has the functionality provided by those technologies) that it is impossible to predict how people will be using them through the life of this strategy. However, at minimum, we would expect to see:
- increased use of social networking sites to connect with others, converse and share information (for example, in only a few months, the Change4Life Facebook page has grown to over 45,000 “fans”, who, with minimal interference or moderation from the centre, discuss and swap ideas for healthier lifestyles);
- people expecting to be able to find information and tools where they choose to be, rather than at the brand owner’s site (which will require us to create “white-labelled” tools that can be carried on or linked to from partner websites (as we began to do with the Change4Life Great Swapathon on line tool);
- greater use of on line and other technology platforms to access services (in only two years we have seen the proportion of people ordering a smoking cessation Quit Kit “flip” from primarily telephone ordering to primarily online ordering);
- the delivery of products and services through new technologies (a recent example of this is the Drinks App available on NHS Choices. Since its launch in December 2010, 197,000 people have downloaded the drinks tracker app to their iPhones. This is impressive since, in the burgeoning market, only a small percentage of apps become popular. As we go forwards, we will use end-users in the design of our apps (user-centred design) and will build “social functionality” (such as the ability for users to rate and review our apps), since the best rated apps generally become the most popular;
- people joining together to use their power to access discounts (for example via Groupon), which will have implications for how we deliver partner-funded offers (it was a failing of the recent Change4Life Great Swapathon that people were not able to access partner offers online).
8.3.16 Developing our use of social media will be especially important for the youth programme and for families (recent ethnographic research with low-income families found that children were significant drivers of new technology within households and researchers witnessed children as young as three using their own laptop computers). 8.3.17 We should remember, however, that this increase has been driven not by websites offering information, but by those offering music, video, shopping, gaming, gambling and gossip, all of which offer a more interesting and stimulating user experience than most current Government campaigns.
- Individual tools (to support individual responsibility), for example health checkers and monitors and data visualisation tools. For example, Change4Life’s Walkometer app (used over 10,000 times) allowed users to input their daily exercise and see their output over time in terms of calories burned, steps taken or a distance walked. These tools can quantify change and reward people for that change.
- Group tools (recognising people’s need for support) , enabling people to benchmark themselves against others, set goals and make performance against those goals visible to others.
- Aggregating tools, which sort through data to enable people to, for example, find their local park.
- Tools which provide access to expertise or appointment reminders.
- Games, which build health content into gameplay.
The only problem is that as diffusion of innovation theory shows, for every ‘early adopter‘ you have, you will have a lot of ‘late adopters‘ and many of these will also be very likely to be the people with the most challenging health issues. Can we afford in public health marketing for these people to be reached last, when lives are at risk? We would argue that values are a significant influence when it comes to the dynamics of cultural change
- Anything ‘new’ mainly starts with those with inner directed values.
- They then create ‘success bridge’ to get uptake from those with outer directed values.
- Those with sustenance, safety and security values will tend to follow once others have adopted
New behaviours are thus adopted in this order of values which adds to our understanding as to how different people react in a situation where an innovation in behaviour or technology is occurring. However this process takes significant amounts of time, which may not be helpful in a public health context, so it is important to also consider approaches that ‘match motivations’: communicating in various ways in order for people to follow the same behaviour for different motivations in order to satisfy different needs. Finally the report sets out an outline of elements that will be evaluated at a national level. This is a helpful pointer to the development of future Health Premiums proposed in the Public Health White Paper.
Each programme’s evaluation plan will set out in detail the:
- Evaluation objectives.
- KPIs – devised in relation to the desired behavioural outcomes (and in line with best practice, ie output, outtakes, outcomes and impact).
- Methodology and data sources.
We will use a mix of methods, incorporating market research (qualitative and quantitative), commercial sector data (wherever possible, supplied for free as part of our partnership arrangement), online panels, search, buzz monitoring and website analytics as well as other surveys conducted by government departments and agencies, such as Health Survey of England. Our increased use of social media and digital tools will generate vast amounts of behavioural data, which will be used in tracking citizen behaviours.
In conclusion, it is good to see the development of a clear strategy in these uncertain times; however it is important that at a time of expenditure reductions, changes are phased and that replacement services are tested through insight research that examines new approaches with all segments of the community. This might then avoid some of the problems over take-up of services that so interested the national media over the weekend! Charlie Mansell is Research and Development Officer for The Campaign Company. If you want to see what your own primary values set is, why not take the simple Values Questionnaire here.