Social marketing in public health

Church-based social marketing to motivate older adults to take balance classes for fall prevention: cluster randomized controlled trial

OBJECTIVE

Determine whether a church-based social marketing program increases older adults' participation in balance classes for fall prevention.

METHODS

In 2009-10, 51 churches (7101 total members aged ≥ 60) in Colorado, U.S.A. were randomized to receive no intervention or a social marketing program. The program highlighted benefits of class participation (staying independent, building relationships), reduced potential barriers (providing convenient, subsidized classes), and communicated marketing messages through church leaders, trained "messengers," printed materials and church-based communication channels. Between-group differences in balance class enrollment and marketing message recall among congregants were compared using Wilcoxon Two-Sample Test and regression models.

RESULTS

Compared to 25 control churches, 26 churches receiving the social marketing program had a higher median proportion (9.8% vs. 0.3%; p<0.001) and mean number (7.0 vs. 0.5; IRR=11.2 [95%CI: 7.5, 16.8]) of older adult congregants who joined balance classes. Intervention church members were also more likely to recall information about preventing falls with balance classes (AOR=6.2; 95% CI: 2.6, 14.8) and availability of classes locally (AOR=7.7; 95% CI: 2.6, 22.9).

CONCLUSIONS

Church-based social marketing effectively disseminated messages about preventing falls through balance classes and, by emphasizing benefits and reducing barriers and costs of participation, successfully motivated older adults to enroll in the classes.

Challenges to obtaining parental permission for child participation in a school-based waterpipe tobacco smoking prevention intervention in Qatar

BACKGROUND

Involving children in research studies requires obtaining parental permission. A school-based intervention to delay/prevent waterpipe use for 7th and 8th graders in Qatar was developed, and parental permission requested. Fifty three percent (2308/4314) of the parents returned permission forms; of those 19.5% of the total (840/4314) granted permission. This paper describes the challenges to obtaining parental permission. No research to date has described such challenges in the Arab world.

METHODS

A random sample of 40 schools in Doha, Qatar was selected for inclusion in the original intervention. Permission forms were distributed to parents for approval of their child's participation. The permission forms requested that parents indicate their reasons for non-permission if they declined. These were categorized into themes. In order to understand reasons for non-permission, interviews with parents were conducted. Phone numbers of parents were requested from the school administration; 12 of the 40 schools (30%) agreed to provide the contact information. A random sample of 28 parents from 12 schools was interviewed to reach data saturation. Thematic analysis was used to analyze their responses.

RESULTS

Reasons for non-permission documented in both the forms and interviews included: poor timing; lack of interest; the child not wanting to participate; and the child living in a smoke-free environment. Interviews provided information on important topics to include in the consent forms, parents' decision-making processes regarding their child's participation, and considerations for communicating with parents. Many parents also indicated that this was the first time they had been asked to give an informed consent for their child's participation in a study.

CONCLUSIONS

Results indicate that more attention needs to be given to the informed parental consent process. Researchers should consider enhancing both the methods of communicating information as well the specific information provided. Before embarking on recruitment of children for studies, formative research on the parental consent process is suggested.

Use of market research data by state chronic disease programs, Illinois, 2012-2014

Market research data complement traditional epidemiologic data by allowing users to examine health behavior and patterns by census block or census tract. Market research data can identify products and behaviors that align or do not align with public health program goals. Illinois is a recipient of an award from the Directors of Health Promotion and Education to use industry market research data collected by The Nielsen Company for public health purposes. Illinois creates customized community profiles using market research data on tobacco use characteristics to describe the demographics, habits, and media preferences of smokers in certain locations. Local agencies use profiles to plan and target marketing initiatives, reach disparate groups within overall community populations, and restructure program objectives and policy initiatives. Local market research data provide detailed information on the characteristics of smokers, allowing Illinois communities to design public health programs without having to collect data on their own.

What is the public appetite for healthy eating policies? Evidence from a cross-European survey

World Health Organization estimates that obesity accounts for 2-8% of health care costs in different parts of Europe, and highlights a key role for national policymaking in curbing the epidemic. A variety of healthy-eating policy instruments are available, ranging from more paternalistic policies to those less intrusive. Our aim is to measure and explain the level of public support for different types of healthy eating policy in Europe, based on data from a probabilistic sample of 3003 respondents in five European countries. We find that the main drivers of policy support are attitudinal factors, especially attribution of obesity to excessive availability of unhealthy foods, while socio-demographic characteristics and political preferences have little explanatory power. A high level of support for healthy eating policy does not translate into acceptance of higher taxes to fund them, however.

Check Yourself: a social marketing campaign to increase syphilis screening in Los Angeles County

BACKGROUND

In 2007, the Los Angeles County Department of Public Health launched Check Yourself, a new social marketing campaign, as part of ongoing efforts to address the persistent syphilis epidemic among men who have sex with men (MSM) in the county. The goals of the campaign were to increase syphilis testing and knowledge among MSM. Check Yourself was planned with careful attention to the principles of social marketing, including formative research, market segmentation, and an emphasis on building a strong brand.

METHODS

A cross-sectional survey using a time-location sample was conducted in 2009 for the evaluation. The survey assessed demographics, syphilis knowledge, and recent syphilis testing as well as unaided awareness, aided awareness, and confirmed awareness, meaning that a person had both awareness of the campaign and could correctly identify that the campaign was about syphilis. The total sample size was 306.

RESULTS

Unaided awareness for Check Yourself was 20.7%, and aided awareness was 67.5%, bringing total campaign awareness to 88.2%; confirmed awareness was 30.4%. Unaided campaign awareness was associated with syphilis knowledge and important risk behaviors for syphilis, indicating that the campaign reached an appropriate audience. Total awareness was not associated with recent syphilis testing in a multivariate model. However, MSM with confirmed awareness were more than 6 times more likely to have been recently tested.

CONCLUSIONS

The evaluation of Check Yourself found that the campaign had a very strong brand among MSM. Although total awareness was not associated with syphilis testing, confirmed awareness, a more robust measure, was strongly associated.

Developing a Dissemination Model to Improve Intervention Reach among West Virginia Youth Smokers

The not-on-tobacco program is an evidence-based teen smoking cessation program adopted by the American Lung Association (ALA). Although widely disseminated nationally via ALA Master Trainers, in recent years, adoption and implementation of the N-O-T program in West Virginia (WV) has slowed. WV, unfortunately, has one of the highest smoking rates in the US. Although it is a goal of public health science, dissemination of evidence-based interventions is woefully understudied. The present manuscript reviews a theoretical model of dissemination of the not-on-tobacco program in WV. Based on social marketing, diffusion of innovations, and social cognitive theories, the nine-phase model incorporates elements of infrastructure development, accountability, training, delivery, incentives, and communication. The model components as well as preliminary lessons learned from initial implementation are discussed.

Eating for the better: a social marketing review (2000-2012)

OBJECTIVE

The present study sought to identify both the ingredients for success and the potential impediments to social marketing effectiveness for healthy eating behaviour, focusing on studies conducted over the last 10 years.

DESIGN

A comprehensive literature review was undertaken examining seventeen databases to identify studies reporting the use of social marketing to address healthy eating. Thirty-four empirical studies were analysed to examine the effectiveness of social marketing interventions to improve healthy eating behaviour using Andreasen's (2002) social marketing benchmark criteria. Statistical analysis was undertaken to quantitatively evaluate whether effectiveness varied between study categories (subsets).

SETTING

Healthy eating empirical studies published from 2000 onwards.

SUBJECTS

Empirical studies that self-identified as social marketing.

RESULTS

Sixteen social marketing studies (subset 1) were identified in the review. These were systematic studies which sought to change behaviour through tailored solutions (e.g. use of marketing tools beyond communication was clearly evident) that delivered value to the target audience. For these sixteen studies, the mean number of criteria identified was five. Six studies met all six criteria. Positive change to healthy eating behaviour was found in fourteen of sixteen studies. The sixteen studies that met the definition of social marketing used significantly more of Andreasen's (2002) criteria and were more effective in achieving behavioural change than the eighteen studies in subset 2.

CONCLUSIONS

Social marketing is an involved process and it is important that studies identifying as social marketing adopt social marketing benchmark criteria. Social marketing when employed to its full extent offers the potential to change healthy eating.

Using marketing theory to inform strategies for recruitment: a recruitment optimisation model and the txt2stop experience

BACKGROUND

Recruitment is a major challenge for many trials; just over half reach their targets and almost a third resort to grant extensions. The economic and societal implications of this shortcoming are significant. Yet, we have a limited understanding of the processes that increase the probability that recruitment targets will be achieved. Accordingly, there is an urgent need to bring analytical rigour to the task of improving recruitment, thereby increasing the likelihood that trials reach their recruitment targets. This paper presents a conceptual framework that can be used to improve recruitment to clinical trials.

METHODS

Using a case-study approach, we reviewed the range of initiatives that had been undertaken to improve recruitment in the txt2stop trial using qualitative (semi-structured interviews with the principal investigator) and quantitative (recruitment) data analysis. Later, the txt2stop recruitment practices were compared to a previous model of marketing a trial and to key constructs in social marketing theory.

RESULTS

Post hoc, we developed a recruitment optimisation model to serve as a conceptual framework to improve recruitment to clinical trials. A core premise of the model is that improving recruitment needs to be an iterative, learning process. The model describes three essential activities: i) recruitment phase monitoring, ii) marketing research, and iii) the evaluation of current performance. We describe the initiatives undertaken by the txt2stop trial and the results achieved, as an example of the use of the model.

CONCLUSIONS

Further research should explore the impact of adopting the recruitment optimisation model when applied to other trials.

Impact of different policies on unhealthy dietary behaviors in an urban adult population: an agent-based simulation model

OBJECTIVES

Unhealthy eating is a complex-system problem. We used agent-based modeling to examine the effects of different policies on unhealthy eating behaviors.

METHODS

We developed an agent-based simulation model to represent a synthetic population of adults in Pasadena, CA, and how they make dietary decisions. Data from the 2007 Food Attitudes and Behaviors Survey and other empirical studies were used to calibrate the parameters of the model. Simulations were performed to contrast the potential effects of various policies on the evolution of dietary decisions.

RESULTS

Our model showed that a 20% increase in taxes on fast foods would lower the probability of fast-food consumption by 3 percentage points, whereas improving the visibility of positive social norms by 10%, either through community-based or mass-media campaigns, could improve the consumption of fruits and vegetables by 7 percentage points and lower fast-food consumption by 6 percentage points. Zoning policies had no significant impact.

CONCLUSIONS

Interventions emphasizing healthy eating norms may be more effective than directly targeting food prices or regulating local food outlets. Agent-based modeling may be a useful tool for testing the population-level effects of various policies within complex systems.

No drama: key elements to the success of an HIV/STI-prevention mass-media campaign

We qualitatively examined gay men's reactions to the national "Drama Downunder" HIV/STI social marketing campaign targeting gay men in Australia to identify key campaign elements that underpinned the demonstrated effectiveness of the campaign. We present findings from six qualitative focus groups held with 49 participants as part of the evaluation of the sexual-health-promotion campaign over 2008-2009. Participants identified attention-grabbing images, a humorous approach, positive and simple tailored messaging, and the use of mainstream media as campaign features crucial in normalizing sexual health testing, driving campaign engagement, and ensuring high message exposure. Our results suggest that designers of future campaigns should strive to balance positive and negative campaign images and messages, and find new ways to engage men with sexual health topics, particularly younger gay men. We discuss the implications of our findings about campaign effectiveness for future health-promotion campaigns and message design.

Multi-dimensional factors associated with unprotected anal intercourse with regular partners among Chinese men who have sex with men in Hong Kong: a respondent-driven sampling survey

Background

The HIV prevalence and incidence among men who have sex with men (MSM) are high. Unprotected anal intercourse (UAI) with male regular partners (RP) is an important but under-emphasized risk behavior. The current study aimed to describe the prevalence of UAI with regular partner and the associated multi-dimensional factors with UAI among MSM in Hong Kong, China.

Methods

Respondent Driven Sampling method was used to recruit participants. A total of 285 participants were recruited, of whom 211 (75.1%) had had anal sex with RP in the last six months and their data were analyzed in this report. Weighed data were presented and logistic regression methods were fit.

Results

Participants’ high risk behaviors in the last six months included high prevalence of having had UAI with RP (45.8%), having had non-regular male sex partners (NRP: 27.3%) and UAI with such partners (18.9%). Adjusted for socio-demographic variables, factors associated with UAI with RP included: 1) substances use prior to having anal sex (65.7% versus 43.8%; AOR =2.36; 95% CI =1.07-5.18), 2) worry that condom use symbolizes mistrust (67.9% versus 44.3%; AOR = 2.91; 95% CI =1.19-7.10), 3) a lower perceived degree of the RP’s acceptance of condom use (91.7% versus 38.3%; AOR = 22.70; 95% CI =6.20-83.10), and 4) a higher level of impulsivity (61.1% versus 35.0%; AOR =4.02; 95% CI = 1.62-9.97). Two of these four variables, substances use (ORm = 2.28, 95% CI = 1.01-5.16) and perceived lower level of RP’s acceptance of condom use (ORm = 17.22; 95% CI = 5.06-58.62) were selected by the forward stepwise logistic regression model.

Conclusions

MSM with RP in Hong Kong is subjected to high risk of HIV transmission. Risk factors of UAI are multi-dimensional and interventions need to take into account factors of structural, interpersonal and individual levels.

Examining the relationship between psychosocial and behavioral proxies for future consumption behavior: self-reported impact and bidding behavior in an experimental auction study on cigarette labeling

Experimental and observational research often involves asking consumers to self-report the impact of some proposed option. Because self-reported responses involve no consequence to the respondent for falsely revealing how he or she feels about an issue, self-reports may be subject to social desirability and other influences that bias responses in important ways. In this article, we analyzed data from an experiment on the impact of cigarette packaging and pack warnings, comparing smokers' self-reported impact (four-item scale) and the bids they placed in experimental auctions to estimate differences in demand. The results were consistent across methods; however, the estimated effect size associated with different warning labels was two times greater for the four-item self-reported response scale when compared to the change in demand as indicated by auction bids. Our study provides evidence that self-reported psychosocial responses provide a valid proxy for behavioral change as reflected by experimental auction bidding behavior. More research is needed to better understand the advantages and disadvantages of behavioral economic methods and traditional self-report approaches to evaluating health behavior change interventions.

Influencing public awareness to prevent male suicide

Purpose

– The purpose of this paper is to report findings from a formative evaluation of a suicide prevention public awareness campaign – Choose Life, North Lanarkshire. The focus is on preventing male suicide. The paper explores how the public campaign supports a co-ordinated and community-based direction for suicide prevention work, and examines how good practice can be identified, spread, and sustained.

Design/methodology/approach

– The paper draws on data collected from March to November 2011, using mixed primary research methods, including a quota survey, discussion groups with the general public, and stakeholder interviews.

Findings

– The campaign effectively raised the suicide awareness of a substantial proportion of those targeted, but with regional variations. It also affected the attitudes and behaviour of those who were highly aware. However, men and women engaged somewhat differently with the campaign. The sports and leisure settings approach was effective in reaching younger men.

Practical implications

– The paper discusses emerging considerations for suicide prevention, focusing on gender and approaches and materials for engaging with the public as “influencers”. There are challenges to target audiences more specifically, provide a clear call to action, and engage the public in a sustained way.

Originality/value

– This paper reflects on insights from a complex programme, exceptional in its focus on targeted sections of the public, especially young males. The paper indicates the importance for research and practice of intersecting dimensions of male identity, stigma and mental health, and other risk and protective factors which can inform campaigns highlighting talk about suicide among men.

Parent and child interactions with two contrasting anti-obesity advertising campaigns: a qualitative analysis

Background

Social marketing has been proposed as a framework that may be effectively used to encourage behaviour change relating to obesity. Social advertising (or mass media campaigning) is the most commonly used social marketing strategy to address the issue of obesity. While social advertising has the potential to effectively communicate information about obesity, some argue that the current framing and delivery of these campaigns are ineffective, and may cause more harm than good.

Methods

We used a qualitative advertising reception study. 150 family groups (comprised of 159 parents and 184 children) were shown two Australian government anti-obesity advertisements: Measure Up (focused on problems associated with obesity) and Swap It (focused on solutions for obesity). Families were engaged in a discussion about the visual appeals, verbal messages and their perceptions about the impact of the advertisements on behavioural change. Open coding techniques and a constant comparative method of analysis was used to interpret the data.

Results

Many parents had strong personal resonance with the visual imagery within the campaigns. While Swap It had strong ‘likeability’ with children, many children believed that the messages about overweight and obesity were less personally relevant because they did not perceive themselves to be overweight. The content and delivery style of the verbal messages (the serious risk focused message in Measure Up compared to the upbeat, fun practical message in Swap It) influenced how different audiences (parents and children) interpreted the information that was presented. Parents assimilated practical and instructive messages, while children assimilated messages about weight loss and weight gain. Parents and children recognised that the campaigns were asking individuals to take personal responsibility for their weight status, and were at times critical that the campaigns did not tackle the broader issues associated with the causes and consequences of obesity. The lack of practical tools to encourage behavioural change was a key barrier for obese parents.

Conclusions

Well-funded, targeted social marketing campaigns will play an important role in the prevention and management of obesity. It is important that these campaigns are comprehensively evaluated and are backed up with structural supports to enable and encourage population subgroups to act upon messages.

Assessment of a healthy corner store program (FIT Store) in low-income, urban, and ethnically diverse neighborhoods in Michigan

This study evaluated a community-based and social marketing healthy corner store program (FIT store) to improve the affordability and availability of healthy foods in low-income, urban, and ethnically diverse neighborhoods in Michigan. The Nutrition Environment Measures Survey in Stores data were analyzed for the FIT (N = 4) stores. Two cross-sectional surveys were conducted among the FIT store customers before (N = 401) and after (N = 318) the intervention. Three FIT stores improved their total Nutrition Environment Measures Survey in Stores availability score from before to after the intervention. A significantly higher level of FIT awareness and monthly bean and nut consumption was reported in the postintervention.

Guidelines for youth sports clubs to develop, implement, and assess health promotion within its activities

The settings approach to health promotion is a world-known concept concerning settings like city, hospital, school, and workplace. The concept has also been used in some regionally specific settings, such as island, prison, or university. However, there are still many, often noninstitutional, settings that have a lot of potential but have not yet been recognized. One of the newcomers is the youth sports club, which has the potential to reach a lot of children and adolescents and is effective, via its casual educational nature based on voluntary participation. According to research, health is an important aim for most youth sports clubs, but it has not been converted into practical actions. Indeed, the clubs often recognize the importance of healthy lifestyles, but there is a lack of understanding of what to do to reinforce it within one's activities. That is why, on the basis of the results of the Health Promoting Sports Club survey in Finland, guidelines for clubs to enhance health promotion as a part of their activities were created. The aim of this article is to present the guidelines, theirs rationale, and practical examples.

Adolescent asthma self-management: patient and parent-caregiver perspectives on using social media to improve care

BACKGROUND

Self-management of asthma can now leverage new media technologies. To optimize implementation they must employ a consumer-oriented developmental approach. This study explored benefits of and barriers to improved asthma self-management and identified key elements for the development of a digital media tool to enhance asthma control.

METHODS

Between August 2010 and January 2011, 18 teens with asthma and 18 parent-caregivers participated in semistructured in-depth interviews to identify mechanisms for improving asthma self-management and propose characteristics for developing a digital media tool to aid such efforts.

RESULTS

Teens and caregivers enumerated physician-recommended strategies for asthma management as well as currently employed strategies. Both groups thought of a potential digital media solution as positive, but indicated specific design requirements for such a solution to have utility. Whereas most participants perceived mobile platforms to be viable modes to improve asthma self-management, interest in having social networking capabilities was mixed.

CONCLUSIONS

A digital media product capable of tracking conditions, triggers, and related asthma activities can be a core element of improved asthma control for youth. Improved asthma control will help decrease school absenteeism.

Evaluating the effectiveness of an Australian obesity mass-media campaign: how did the 'Measure-Up' campaign measure up in New South Wales?

In 2008, the Australian Government launched a mass-media campaign 'Measure-Up' to reduce lifestyle-related chronic disease risk. Innovative campaign messages linked waist circumference and chronic disease risk. Communication channels for the campaign included television, press, radio and outdoor advertising and local community activities. This analysis examines the impact of the campaign in the state of New South Wales, Australia. Cross-sectional telephone surveys (n = 1006 adults pre- and post-campaign) covered self-reported diet and physical activity, campaign awareness, knowledge about waist circumference, personal relevance of the message, perceived confidence to make lifestyle changes and waist-measuring behaviours. The campaign achieved high unprompted (38%) and prompted (89%) awareness. From pre- to post-campaign, knowledge and personal relevance of the link between waist circumference and chronic disease and waist measuring behaviour increased, although there were no significant changes in reported fruit and vegetable intake nor in physical activity. Knowledge of the correct waist measurement threshold for chronic disease risk increased over 5-fold, adjusted for demographic characteristics. 'Measure-Up' was successful at communicating the new campaign messages. Continued long-term investment in campaigns such as 'Measure-Up', supplemented with community-based health promotion, may contribute to population risk factor understanding and behaviour change to reduce chronic disease.

Couples' notions about preconception health: implications for framing social marketing plans

PURPOSE

To understand couples' notions of preconception health (PCH) and to inform the development of social marketing plans focused on PCH. APPROACH/DESIGN: We used a social marketing perspective to understand how couples considered PCH as a product, its potential price, how it should be promoted, and in what type of places it should be promoted. These variables are typically referred to as the four social marketing P's.

SETTING

Telephone interviews with couples recruited from a national database.

PARTICIPANTS

A total of 58 couples (116 individuals) were segmented by five couple segments based on pregnancy planning intention and current parental status in which the wife or partner was 18 to 44 years of age. The five segments were combined into three categories: couples who were planning pregnancies, couples who were not planning pregnancies, or couples who were recent parents (interconception).

METHOD

Couple-based structured interviews lasting approximately 45 to 60 minutes were conducted via telephone. Questions inquired about couples' experience with PCH and the four social marketing P's.

RESULTS

Commonalities existed across the four social marketing P's for the different couple segments. Notable couple-related themes that emerged included the importance of couple communication, support, and relationship quality. PCH was more relevant for couples planning a pregnancy, but nonplanning couples understood the benefits of PCH and related behaviors.

CONCLUSION

Couples may be an important target audience when considering social marketing approaches for PCH. Many couples perceived the relevance of the issue to important aspects of their lives, such as health, family, and their relationships.

What constitutes the best sex life for gay and bisexual men? Implications for HIV prevention

Background

While a large body of research has sought to understand HIV transmission risk behaviours among gay men, bisexual men and other men who have sex with men (MSM), less attention has been paid to the wider sexual health and well-being of this population. While some community-based organisations aim to support a more holistic sense of sexual well-being there is little evidence to draw on to inform their interventions. The current study sought to explore gay and bisexual men’s conceptions of what constitutes the ‘best sex’.

Method

The EMIS survey of 2010 recruited more than 180,000 respondents from 38 European countries to complete an online questionnaire about sexual health and behaviour. The 12,942 English language, UK-based responses to the open ended question, “What’s your idea of the best sex life?” were subjected to a detailed content analysis. A framework was devised to reflect and describe the key themes emerging from the data, which was then used to code all responses to one (or more) of these themes. Further statistical analysis sought to establish if and how responses differed according to key demographic variables.

Results

Eight themes emerged that capture the diversity of gay and bisexual men’s sexual desires. Most common among responses was a desire for sex within committed relationships, followed by a desire for sex which is emotionally or psychologically connected. Men also expressed a desire for volume and variety in their sexual lives, and for sex that is free from physical, social or psychological harm. Comparative analysis identified that older men were less likely to idealise a relationship or emotional connection, but were more likely to specify the sexual acts or behaviours they wished to engage in.

Conclusions

Attending to what men value or aspire to can help ensure interventions are engaging and meaningful to the target population. HIV prevention interventions need to attend to the broad range of sexual desires held by gay and bisexual men in delivery of holistic sexual health promotion that can help them to have the best sex with the least harm.

Overcoming Challenges to Build Strong Physical Activity Promotion Messages

Physical inactivity is a serious public health issue. Physical activity promotion messages are part of a comprehensive approach to creating a society in which physical activity is the norm. Although public health messages can be influential, they face tough competition from other sources of physical activity information that offer conflicting advice about being active and thus may undermine public health efforts. It is therefore necessary to consider the multiple sources of messages (eg, commercial, public health) that can cause confusion for consumers. This article reviews research on sources of physical activity information, where such information is sought and by whom, and how messages are processed at both automatic (ie, with little thought) and reasoned (ie, deliberate) levels. Having outlined the challenges, suggestions are made regarding how public health messages can be heard in an environment dominated by commercial advertising. These suggestions include tailoring theory-based messages, ensuring the benefits of being active are highlighted, branding, and forging collaborative partnerships within the physical activity sector. By enacting these strategies, public health messages may be more effective at attracting attention and being subsequently read and recalled by consumers, and thus contribute to an active society.

Mosaic segmentation, COPD and CHF multimorbidity and hospital admission costs: a clinical linkage study

BACKGROUND

How multimorbidity and socio-economic factors influence healthcare costs is unknown. Geo-demographic profiling system, Mosaic, which adds to socio-economic factors, provides the potential for an investigation of the relationship with multimorbidity, and their influence on healthcare costs.

METHODS

Using chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) registers from 53 general practices for a population aged 40 years and over in Stoke-on-Trent, England (N = 10,113), were linked to hospital admissions data and Healthcare Resource Groups as a measure of hospital cost (2007-09). Eleven Mosaic groups were linked on the basis of individual patients' post codes.

RESULTS

The COPD and CHF multimorbid group (n = 763) had the highest proportion with at least one hospital admission in the 3-year time period (n = 550, 72%), compared with the index COPD (56%) and CHF (66%) groups. Multimorbid patients had significantly higher mean costs for hospital admission (£4896) compared with the index COPD (£2769) or CHF (£3876). The associations between multimorbid groups and hospital admission costs compared with index groups varied by different Mosaic groups.

CONCLUSIONS

CHF and COPD multimorbidity is associated with high costs, and average hospital admission costs vary by Mosaic segmentation. Multimorbidity and Mosaic provide an innovative basis for developing and targeting healthcare interventions in high-hospital-cost patients.

New methods for assessing the fascinating nature of nature experiences

In recent years, numerous environmental psychology studies have demonstrated that contact with nature as opposed to urban settings can improve an individual’s mood, can lead to increased levels of vitality, and can offer an opportunity to recover from stress. According to Attention Restoration Theory (ART) the restorative potential of natural environments is situated in the fact that nature can replenish depleted attentional resources. This replenishment takes place, in part, because nature is deemed to be a source of fascination, with fascination being described as having an “attentional”, an “affective” and an “effort” dimension. However, the claim that fascination with nature involves these three dimensions is to a large extent based on intuition or derived from introspection-based measurement methods, such as self-reports. In three studies, we aimed to more objectively assess whether these three dimensions indeed applied to experiences related to natural environments, before any (attentional) depletion has taken place. The instruments that were used were: (a) the affect misattribution procedure (Study 1), (b) the dot probe paradigm (Study 2) and (c) a cognitively effortful task (Study 3). These instrument were respectively aimed at verifying the affective, attentional and effort dimension of fascination. Overall, the results provide objective evidence for the claims made within the ART framework, that natural as opposed to urban settings are affectively positive (cfr., affective dimension) and that people have an attentional bias to natural (rather than urban) environments (cfr., attentional dimension). The results regarding the effort dimension are less straightforward, and suggest that this dimension only becomes important in sufficiently difficult cognitive tasks.

Gender policies and advertising and marketing practices that affect women's health

BACKGROUND

The three papers of this doctoral thesis are based on the social construction of reality through the analysis of communication relating to health issues. We have analysed the contents of parliamentary, institutional, and mass media to uncover whether their communications create, transmit, and perpetuate gender biases and/or stereotypes, which may have an impact on peoples' health, with a particular focus on women.

OBJECTIVE

To analyse decision making and the creation of gender awareness policies and actions affecting women's health: (1) political debates about abortion, (2) gender awareness communication campaigns and educational actions, and (3) pharmaceutical advertising strategies.

DESIGN

Quantitative and qualitative methods were employed, and the research included observational studies and systematic reviews. To apply a gender perspective, we used the level of gender observation proposed by S. Harding, which states that: (1) gender is the basis of social norms and (2) gender is one of the organisers of the social structure.

RESULTS

Sixty percentage of the bills concerning abortion introduced in the Spanish Parliament were initiated and led by pro-choice women's groups. Seventy-nine percent of institutional initiatives aimed at promoting equality awareness and were in the form of educational actions, while unconventional advertising accounted for 6 percent. Both initiatives focused on occupational equality, and very few actions addressed issues such as shared responsibility or public policy. With regard to pharmaceutical advertising, similar traditional male-female gender roles were used between 1975 and 2005.

CONCLUSIONS

Gender sensitivity continues to be essential in changing the established gender system in Spanish institutions, which has a direct and indirect impact on health. Greater participation of women in public policy and decision-making are critical for womens' health, such as the issue of abortion. The predominance of women as the target group of institutional gender awareness campaigns proves that the gender perspective still lacks the promotion of shared responsibilities between men and women. There is a need for institutions that act as 'policy watchdogs' to control the gender biases in mass media and pharmaceutical marketing as well as to ensure the proper implementation and maintenance of Spanish equality laws.

Effectiveness of alcohol prevention interventions based on the principles of social marketing: a systematic review

Background

Alcohol education aims to increase knowledge on the harm related to alcohol, and to change attitudes and drinking behaviour. However, little (lasting) evidence has been found for alcohol education, in changing alcohol-related attitudes and behaviour. Social marketing uses marketing techniques to achieve a social or healthy goal, and can be used in alcohol education. Social marketing consists of eight principles: customer orientation, insight, segmentation, behavioural goals, exchange, competition, methods mix, and is theory based. This review investigates the application of social marketing in alcohol prevention interventions, and whether application of social marketing influences alcohol-related attitudes or behaviour.

Method

A literature search was conducted in PubMed, PsychInfo, Cochrane and Scopus. Inclusion criteria were that original papers had to describe the effects of an alcohol prevention intervention developed according to one or more principles of social marketing. No limits were set on the age of the participants or on the kind of alcohol prevention intervention. The abstracts of the 274 retrieved studies were reviewed and the full texts of potentially relevant studies were screened.

Results

Six studies met the inclusion criteria and were included in this review. These six studies showed associations for the application of social marketing techniques on alcohol-related attitudes or behaviour; one study relates to participation in a drinking event, four to alcohol drinking behaviour, two to driving a car while under the influence of alcohol, two to recognition of campaign messages or campaign logo, and one to awareness of the campaign. However, no associations were also found. In addition, the studies had several limitations related to a control group, response rate and study methodology.

Conclusion

Based on this review, the effect of applying the principles of social marketing in alcohol prevention in changing alcohol-related attitudes or behaviour could not be assessed. More research, with a good quality methodology, like using a randomized control trial and measuring short, medium, and long-term effects, is required on this topic. Policy implications are discussed.

The asthma knowledge and perceptions of older Australian adults: implications for social marketing campaigns

OBJECTIVE

The purpose of this research is to gain an understanding of the asthma perceptions of older adults and identify gaps in their asthma knowledge.

METHODS

In regional New South Wales, Australia, a stratified, random sample of 4066 adults, aged 55 years and over, both with and without an asthma diagnosis, completed a survey based on the Health Belief Model about asthma knowledge and perceptions.

RESULTS

Almost half of the sample had experienced symptoms of breathlessness in the past four weeks. Breathlessness was a predictor of lower health ratings and poorer mood. Older adults reported low susceptibility to developing asthma. The sample demonstrated poor knowledge of key asthma symptoms including shortness of breath, tightness in the chest and a cough at night.

CONCLUSION

There is a general lack of asthma awareness in this age group. This could result in not seeking medical help, and thus a reduced quality of life.

PRACTICAL IMPLICATIONS

Older adults should be made aware of key symptoms and the prevalence of asthma in the older adult population, and be empowered to take control of their respiratory health. Audience segmentation for an intervention should be based on recent experience of breathlessness and asthma diagnosis.

Smoking, mental illness and socioeconomic disadvantage: analysis of the Australian National Survey of Mental Health and Wellbeing

BACKGROUND

High rates of smoking and lower rates of smoking cessation are known to be associated with common mental disorders such as anxiety and depression, and with individual and community measures of socioeconomic status. It is not known to what extent mental illness and socioeconomic status might be jointly associated with smoking behaviour. We set out to examine the relationship between mental illness, measures of socioeconomic disadvantage and both current smoking and smoking cessation rates.

METHODS

We used data from the 2007 Australian National Survey of Mental Health and Wellbeing to examine the relationship between mental illness, socioeconomic status and both current smoking and smoking cessation. We used cross-classified tables and logistic regression to examine the relationship between psychosocial and sociodemographic predictors and current smoking. We also used proportional hazards regression to examine the relationship between the factors and smoking cessation.

RESULTS

Both mental illness and socioeconomic status were independently associated with current smoking and with lower likelihood of smoking cessation, with gradients in smoking by mental health status being observed within levels of socioeconomic indicators and vice versa. Having a mental illness in the past 12 months was the most prevalent factor strongly associated with smoking, affecting 20.0% of the population, associated with increased current smoking (OR 2.43; 95% CI: 1.97-3.01) and reduced likelihood of smoking cessation (HR: 0.77; 95% CI: 0.65-0.91).

CONCLUSIONS

The association between mental illness and smoking is not explained by the association between mental illness and socioeconomic status. There are strong socioeconomic and psychosocial gradients in both current smoking and smoking cessation. Incorporating knowledge of the other adverse factors in smokers' lives may increase the penetration of tobacco control interventions in population groups that have historically benefitted less from these activities.

Short Text Messages to Motivate HIV Testing Among Men Who have Sex with Men: A Qualitative Study in Lima, Peru

Objective:

The objective of this study is to identify features and content that short message service (SMS) should have in order to motivate HIV testing among men who have sex with men (MSM) in Lima, Peru.

Methods:

From October, 2010 to February, 2011, we conducted focus groups at two stages; six focus groups were conducted to explore and identify SMS content and features and two additional focus groups were conducted to tailor SMS content. The text messages were elaborated within the theoretical framework of the Information-Motivation-Behavioral Skills model and the Social Support Theory.

Results:

A total of 62 individuals participated in the focus groups. The mean age of participants was 28 years (range 18-39). We identified important features and content items needed for the successful delivery of text messages, including: a) the use of neutral and coded language; b) appropriate frequency and time of delivery; c) avoiding mass and repetitive messages; and d) use of short, concise and creative messages. Although in Peru receiving text messages is usually a free service, it is important to remind participants that receiving messages will be free of charge.

Conclusion:

Text messages can be used to promote HIV testing among Peruvian MSM. It is important to consider adequate frequency, message content and cost when delivering messages to promote HIV testing in this population.

Reducing hospital associated infection: a role for social marketing

PURPOSE

Although hand hygiene is seen as the most important method to prevent the transmission of hospital associated infection in the UK, hand hygiene compliance rates appear to remain poor. This research aims to assess the degree to which social marketing methodology can be adopted by a particular organisation to promote hand hygiene compliance.

DESIGN/METHODOLOGY/APPROACH

The research design is based on a conceptual framework developed from analysis of social marketing literature. Data collection involved taped interviews given by nursing staff working within a specific Hospital Directorate in Manchester, England. Supplementary data were obtained from archival records of the hand hygiene compliance rates.

FINDINGS

Findings highlighted gaps in the Directorate's approach to the promotion of hand hygiene compared to what could be using social marketing methodology. Respondents highlighted how the Directorate failed to fully optimise resources required to endorse hand hygiene practice and this resulted in poorer compliance.

PRACTICAL IMPLICATIONS

From the experiences and events documented, the study suggests how the emergent phenomena could be utilised by the Directorate to apply a social marketing approach which could positively influence hand hygiene compliance.

ORIGINALITY/VALUE

The paper seeks to explore the use of social marketing in nursing to promote hand hygiene compliance and offer a conceptual framework that provides a way of measuring the strength of the impact that social marketing methodology could have.

A matched pair cluster randomized implementation trail to measure the effectiveness of an intervention package aiming to decrease perinatal mortality and increase institution-based obstetric care among indigenous women in Guatemala: study protocol

BACKGROUND

Maternal and perinatal mortality continue to be a high priority problem on the health agendas of less developed countries. Despite the progress made in the last decade to quantify the magnitude of maternal mortality, few interventions have been implemented with the intent to measure impact directly on maternal or perinatal deaths. The success of interventions implemented in less developed countries to reduce mortality has been questioned, in terms of the tendency to maintain a clinical perspective with a focus on purely medical care separate from community-based approaches that take cultural and social aspects of maternal and perinatal deaths into account. Our innovative approach utilizes both the clinical and community perspectives; moreover, our study will report the weight that each of these components may have had on reducing perinatal mortality and increasing institution-based deliveries.

METHODS/DESIGN

A matched pair cluster-randomized trial will be conducted in clinics in four rural indigenous districts with the highest maternal mortality ratios in Guatemala. The individual clinic will serve as the unit of randomization, with 15 matched pairs of control and intervention clinics composing the final sample. Three interventions will be implemented in indigenous, rural and poor populations: a simulation training program for emergency obstetric and perinatal care, increased participation of the professional midwife in strengthening the link between traditional birth attendants (TBA) and the formal health care system, and a social marketing campaign to promote institution-based deliveries. No external intervention is planned for control clinics, although enhanced monitoring, surveillance and data collection will occur throughout the study in all clinics throughout the four districts. All obstetric events occurring in any of the participating health facilities and districts during the 18 months implementation period will be included in the analysis, controlling for the cluster design. Our main outcome measures will be the change in perinatal mortality and in the proportion of institution-based deliveries.

DISCUSSION

A unique feature of this protocol is that we are not proposing an individual intervention, but rather a package of interventions, which is designed to address the complexities and realities of maternal and perinatal mortality in developing countries. To date, many other countries, has focused its efforts to decrease maternal mortality indirectly by improving infrastructure and data collection systems rather than on implementing specific interventions to directly improve outcomes.

TRIAL REGISTRATION

ClinicalTrial.gov,http://NCT01653626.

Promoting Asthma Awareness to Older Adults

The limited existing research on the asthma perceptions of older adults suggests that this population perceives asthma to be a childhood disease and, therefore, believe that they are not susceptible to developing the condition as an adult. The asthma mortality rate is much higher for older adults than for children, and there is considerable negative impact on health-related quality of life. However, health promotion regarding asthma is rarely aimed at this population. To address this issue, social marketing campaign messages and materials about asthma were developed for an older adult population based on quantitative survey data. Through a series of community focus groups, these messages and materials were pretested with older adults to establish the types of asthma health promotion messages, taglines, and images that engage this target audience. Materials that conveyed a “human element” appealed most to older adults, enabling them to relate to the individuals and situations depicted in the images. Positive, empowering messages containing novel information and asking questions of the target population resonated best with older adults. These features should be considered in the development of health promotion campaign materials about chronic disease targeting older adult populations.

Social marketing and breastfeeding: a literature review

Aims:

Through the review of relevant literature this study illuminates the concepts of social marketing and breastfeeding. It specifically discusses the positioning of the link between social marketing and breastfeeding within different fields of study and develops a theoretical framework that tries to bridge the gap between those disciplines.

Method:

Various electronic databases were used and through systematic selection 11 scientific articles were identified that this literature review is based on.

Results:

The review indicates that the relationship between social marketing and breastfeeding is complex. There are indications that this relationship is being investigated within three distinct fields of research: psychology/education, public health and marketing. Depending on the research field the emphasis is put on either breastfeeding or social marketing as well as on the other concepts that were discovered to be of importance within this relationship. Namely, group and individual demography as well as behaviour were revealed to be important elements of the link between social marketing and breastfeeding.

Conclusions:

Based on the results this study concludes that a more multidimensional view on the relationship between the concepts under study is needed since the focus of previous studies is very one-sided and limited to just one element when all elements should be integrated equally.

Motivating men who have sex with men to get tested for HIV through the internet and mobile phones: a qualitative study

BACKGROUND

Men who have sex with men (MSM) have the highest HIV prevalence in Peru, yet they are underserved by traditional preventive programs. In Peru, the Internet and mobile phones have emerged as an effective and convenient tool to reach this population.

METHODS AND FINDINGS

From October 2010 to February 2011, we conducted eight focus groups with gay identified MSM (closeted and out-of-the-closet) and with self-identified heterosexual MSM in order to identify key features and preferences to be used to tailor culturally-appropriate messages that could be delivered through Internet and mobile phones to motivate MSM to get tested for HIV. Participants reported that in order to motivate HIV testing among MSM, interventions need to be based on motivational messages that encourage participants to overcome the fear of getting tested. Messages should increase the HIV risk perception (of participants who do not consider themselves at risk) by eliciting risky situations experienced by MSM. Messages should emphasize confidentiality, respect and the professionalism of the personnel conducting the counseling and testing. A thorough explanation of the process of HIV testing and the steps to follow after receiving the results should be provided. Messages should also contain information about the venue where the test will be conducted in terms of client characteristics, location, hours of operation and personnel. Finally, stigmatizing and stereotyping messages or images about "being gay" should not be included, as they act as deterrents for getting tested.

CONCLUSIONS

Interventions aimed at motivating HIV testing among MSM should include motivational messages that reduce the fear of getting tested and increase the risk perception of participants. They should also market the venue where the testing will be conducted, the professionals who will perform the tests, and the type of tests available. Stigmatizing messages or images should be avoided.

Mobile phone applications for the care and prevention of HIV and other sexually transmitted diseases: a review

BACKGROUND

Mobile phone applications (apps) provide a new platform for delivering tailored human immunodeficiency virus (HIV) and sexually transmitted disease (STD) prevention and care.

OBJECTIVE

To identify and evaluate currently available mobile phone apps related to the prevention and care of HIV and other STDs.

METHODS

We searched the Apple iTunes and Android Google Play stores for HIV/STD-related apps, excluding apps that exclusively targeted industry, providers, and researchers. Each eligible app was downloaded, tested, and assessed for user ratings and functionality as well as 6 broad content areas of HIV prevention and care: HIV/STD disease knowledge, risk reduction/safer sex, condom promotion, HIV/STD testing information, resources for HIV-positive persons, and focus on key populations.

RESULTS

Search queries up to May 2012 identified 1937 apps. Of these, 55 unique apps met the inclusion criteria (12 for Android, 29 for iPhone, and 14 for both platforms). Among these apps, 71% provided disease information about HIV/STDs, 36% provided HIV/STD testing information or resources, 29% included information about condom use or assistance locating condoms, and 24% promoted safer sex. Only 6 apps (11%) covered all 4 of these prevention areas. Eight apps (15%) provided tools or resources specifically for HIV/STD positive persons. Ten apps included information for a range of sexual orientations, 9 apps appeared to be designed for racially/ethnically diverse audiences, and 15 apps featured interactive components. Apps were infrequently downloaded (median 100-500 downloads) and not highly rated (average customer rating 3.7 out of 5 stars).

CONCLUSIONS

Most available HIV/STD apps have failed to attract user attention and positive reviews. Public health practitioners should work with app developers to incorporate elements of evidence-based interventions for risk reduction and improve app inclusiveness and interactivity.

Using science to improve communications about suicide among military and veteran populations: looking for a few good messages

Concern about suicide in US military and veteran populations has prompted efforts to identify more effective prevention measures. Recent expert panel reports have recommended public communications as one component of a comprehensive effort. Messaging about military and veteran suicide originates from many sources and often does not support suicide prevention goals or adhere to principles for developing effective communications. There is an urgent need for strategic, science-based, consistent messaging guidance in this area. Although literature on the effectiveness of suicide prevention communications for these populations is lacking, this article summarizes key findings from several bodies of research that offer lessons for creating safe and effective messages that support and enhance military and veteran suicide prevention efforts.

Stop the drama Downunder: a social marketing campaign increases HIV/sexually transmitted infection knowledge and testing in Australian gay men

INTRODUCTION

Since 2000, notifications of HIV and other sexually transmitted infections (STIs) have increased significantly in Australian gay men. We evaluated the impact of a social marketing campaign in 2008-2009 aimed to increase health-seeking behavior and STI testing and enhance HIV/STI knowledge in gay men.

METHODS

A convenience sample of 295 gay men (18-66 years of age) was surveyed to evaluate the effectiveness of the campaign. Participants were asked about campaign awareness, HIV/STI knowledge, health-seeking behavior, and HIV/STI testing. We examined associations between recent STI testing and campaign awareness. Trends in HIV/STI monthly tests at 3 clinics with a high case load of gay men were also assessed. Logistic and Poisson regressions and χ tests were used.

RESULTS

Both unaided (43%) and aided (86%) campaign awareness was high. In a multivariable logistic regression, awareness of the campaign (aided) was independently associated with having had any STI test within the past 6 months (prevalence ratio = 1.5; 95% confidence interval = 1.0-2.4. Compared with the 13 months before the campaign, clinic data showed significant increasing testing rates for HIV, syphilis, and chlamydia among HIV-negative gay men during the initial and continued campaign periods.

CONCLUSION

These findings suggest that the campaign was successful in achieving its aims of increasing health-seeking behavior, STI testing, and HIV/STI knowledge among gay men in Victoria.

Marketing the HIV test to MSM: ethnic differences in preferred venues and sources

Lack of awareness of HIV status is associated with an increased likelihood of HIV transmission. We surveyed 633 men who have sex with men (MSM) from diverse ethnic groups recruited from a variety of community venues in a U.S. Midwestern city with rising HIV infection rates. Our first aim was to describe patterns of sexual risk, annual HIV testing frequency, and venues where information about HIV and HIV testing could be disseminated to inner-city MSM. Our second aim was to identify preferred sources to receive information about HIV testing and determine whether these preferences differed by ethnic background. Results indicated that despite similar proportions of high-sexual risk behaviors, compared with African American and Latino MSM, smaller proportions of non-Hispanic White MSM had received an HIV test in the last 12 months. Despite ethnic differences in health care access, a physician's office was the most common HIV testing site. Overall, a majority conveyed a preference to see advertisements in mainstream media outlets. However, when preferences were stratified by ethnicity, African American MSM were the least likely to prefer receiving information from mainstream media and conveyed a stronger preference to receive information from authority figures than non-Hispanic White and Hispanic MSM.

Formative process evaluation for implementing a social marketing intervention to increase walking among African Americans in the Positive Action for Today's Health trial

OBJECTIVES

Evaluating programs targeting physical activity may help to reduce disparate rates of obesity among African Americans. We report formative process evaluation methods and implementation dose, fidelity, and reach in the Positive Action for Today's Health trial.

METHODS

We applied evaluation methods based on an ecological framework in 2 community-based police-patrolled walking programs targeting access and safety in underserved African American communities. One program also targeted social connectedness and motivation to walk using a social marketing approach. Process data were systematically collected from baseline to 12 months.

RESULTS

Adequate implementation dose was achieved, with fidelity achieved but less stable in both programs. Monthly walkers increased to 424 in the walking-plus-social marketing program, indicating expanding program reach, in contrast to no increase in the walking-only program. Increased reach was correlated with peer-led Pride Strides (r = .92; P < .001), a key social marketing component, and program social interaction was the primary reason for which walkers reported participating.

CONCLUSIONS

Formative process evaluation demonstrated that the walking programs were effectively implemented and that social marketing increased walking and perceived social connectedness in African American communities.