AM809001 Marketing Proposal: Digital Age, Auckland International

This case study analyzes the development and implementation of a social marketing communications strategy, focusing on a health behavior change campaign by NHS Health Scotland in partnership with Childsmile. It uses a reflexive, mixed-methods approach, including documentary review, interviews, observations, and a critical review of a needs assessment. The study explores how a Social Ecological Model (SEM) of social marketing communications can be used to deliver behavior change, addressing questions related to institutional involvement, inter-related influences, and achieving empowerment, equity, and social justice. The research delves into the components of the SEM, such as microsystems, mesosystems, exosystems, and macrosystems, to understand their impact on health-related behaviors and the effectiveness of social marketing communications.

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Applying an ecologicalmodelto socialmarketing
communications
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How to cite:
Lindridge,Andrew;MacGaskill,Susan;Gnich,Wendy;Eadie,Douglasand Holme,Ingrid (2013).Applying an
ecologicalmodelto socialmarketing communications.European Journalof Marketing, 47(9) pp.1399–1420.
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c2013 European Journalof Marketing
Version:Accepted Manuscript
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http://dx.doi.org/doi:10.1108/EJM-10-2011-0561
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Applying a social ecological model to social marketing communications
1. Introduction
Social marketing aims to encourage behaviour changes for the greater good of the
population and has been shown to positively affect knowledge, awareness, attitudes and
behaviour in a number of areas (Gordon et al., 2006; Stead et al., 2007). However, although
recognition of the importance of consumer-community oriented and evidence based public
health approaches has increased, those interventions that predominantly rely upon
communication and education have failed to reduce the gap in health status between different
socio-economic groups (Ram, 2006; Zimmerman and Bell, 2006). One possible explanation
for this disparity lies in the increased awareness of economic, environmental and social
influences in determining an individual’s health (Andreasen, 2002).
Wymer (2011) argues that social marketing practitioners and scholars have failed to
consider the effects of the environment and appropriate institutions in delivering positive
behaviour changes. Hence, for social marketing programmes to achieve the aim of delivering
behaviour change, there is a need to address an individual’s inter-relationships within their
environment. Yet these inter-relationships remain unclear and difficult to act upon (Noar and
Zimmerman, 2005), despite calls for an increased research focus on contextual and social
influences on health (Koh et al., 2010; Marmot et al., 2008).
The Social Ecological Model of health behaviour (SEM) addresses these criticisms, by
providing a theoretical framework to understand environmental inter-related influences
affecting an individual’s health related behaviours (Sallis et al., 2008). Such is the prevalence
of the SEM in public health discourse that its application is recommended by the World
Health Organisation (Blas and Kurup, 2010), whilst the Institute of Medicine and the
Association of Schools of Public Health calls for the SEM to be taught to students as an

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effective means of achieving health behaviour change (Gebbie, Rosenstock and Hernandez,
2003).
Considering the importance of the SEM and its application to inter-related influences that
affect health related behaviour, research into their application in social marketing is limited.
For example, Golden and Earp (2012) reviewed the application of the SEM to health
behaviours over the period 1989 – 2008 and noted that despite calls for a more comprehensive
approach to understanding how use of the SEM can help solve public health problems, their
practical application remains uncertain. Furthermore “calls for multilevel interventions that
better incorporate social, institutional, and policy approaches to health promotion have gone
largely unheeded” (ibid, p. 397). For example, SEM studies into community and policy
related involvement in health behaviour change accounted for only 20% and 6% of published
papers, whilst only 39% reviewed related institutional level activities. Instead, previously
published research has tended to focus on individual level activities within the SEM (ibid).
Consequently, SEM applications have broadened our understanding of health problems,
without identifying specific influences or providing guidance on improving health
interventions (Glanz, Rimer and Viswanath, 2008; Golden and Earp, 2012).
Application of the SEM to social marketing communications is appropriate where the
emphasis lies in encouraging people to take greater responsibility for health related decisions.
This encouragement is facilitated through bottom-up and top-down approaches to deliver
health behaviour change. The former involves the individuals and their communities
understanding their behaviours and being empowered through alliances to change their
behaviours (Oetzel et al., 2006). For example, the importance of parents and schools in
providing social support (Coker et al., 2002) and positive opinion leaders, such as peers and
spouses, in promoting good health (Durantini, 2006). This is an approach that Dempsey et al.
(2011) argue encapsulates the essential aspects of health promotion: empowerment, equity,

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inclusion, respect and social justice. In contrast, the top-down approach relies upon changes in
policy and institutions to deliver behaviour change. Incorporating both these aspects appears
to deliver effective health promotion campaigns (Jackson et al., 2007). Yet, considering the
widespread recognition of these approaches, there is a lack of clarity regarding the concepts of
social marketing communication and their relevance to public health (McDermott, Stead and
Hastings, 2005; Maibach, Rothschild and Novelli, 2002).
The aim of this paper is to investigate and explore how a SEM of social marketing
communications could be used to deliver behaviour change. In doing so we aim to address
criticisms of the SEM and its application to social marketing communications by attempting
to answer the following questions:
Q1: How can institutions’ involvement in developing social marketing communications
influence behaviour changes to reduce the health status gap between different socio-
economic groups?
Q2: How are social, institutional, and policy inter-related influences that affect health related
behaviours incorporated into social marketing communications?
Q3: By applying a SEM to health orientated social marketing communications, how can
empowerment, equity, inclusion, respect and social justice be achieved?
The aim and questions of this paper are addressed through a case study that analyses the
development and implementation of a social marketing communications strategy to bring
about health behaviour changes. The case study reviews a health behaviour change campaign
undertaken by NHS Health Scotland in partnership with Childsmile, an evolving childhood

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oral health service delivered across Scotland. Using, the development and implementation of
Childsmile’s social marketing communications strategy as a case-study affords exploration of
how a SEM of social marketing communication can be used to deliver behaviour change.
Childsmile aspires to provide access to care for every new-born, combining a targeted and
universal approach to children’s oral health improvement through four programme
components (Core, Practice, Nursery and School). This ‘Integrated Programme’ provides a
comprehensive pathway of care including: supervised nursery tooth-brushing for all 3 to 4
year olds with extended supervision to Primary 1 and 2 classes in disadvantaged areas and
distribution of oral health packs (Childsmile Core); tailored oral health promotion and clinical
prevention in dental practices from 6 months of age with additional support to those families
most at risk of dental caries in the home and community setting from birth (Childsmile
Practice); and clinical preventive (fluoride-varnish) programmes in priority nurseries and
primary schools (Childsmile Nursery and School). Childsmile not only involves programme
staff and other dental and oral health providers, but requires the support of a range of
professionals working with children and families.
2. The Social Ecological Model and its components
Originating in the 1950s (Hawley, 1950), the SEM aims to identify the inter-relationship
and influence of economic, environmental and social influences on the community, inter-
cultural and inter-personal, and institutions within. Developing the SEM further,
Bronfenbrenner (1977, 1979) categorised the SEM as consisting of four inter-related systems:
micro, meso, exo and macro. Recognising how these systems interact with each other offers
opportunities to address them leading to the desired behaviour change, illustrated here by
examples of supporting children’s oral health.

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Microsystems represent aspects of the individual and their social group’s self-identity
affecting their behaviours. For example, the uptake of health orientated behaviours can be
inhibited, or enhanced, by personal motivation, intentions and demographic profile
(O’Donnell, 2005; Ryan and Deci, 2000), such as the parents’ level of education, and attitudes
towards oral health (Grembowski et al., 2008; Holme et al., 2009; Saied-Moallemi et al.,
2008). Consequently, such factors can inhibit parents taking their children to the dentist,
leading to anxiety towards visiting a dentist (Soulliere, 2009), mistaken oral health beliefs and
perceived low importance of primary teeth (Kelly et al., 2005).
Mesosystems represent social structures, including laws (enforced change, such as higher
taxes on cigarettes to discourage smoking), and Government policies (such health orientated
marketing communications) through to encouraging service development, such as child
orientated dental services. For example, in a study of dentists from former East and West
Germany, West German dentists, unlike their Eastern counter-parts were not trained in the
levels of stress that children aged 3-6 years old experience from a visit to the dentist (Splieth
et al., 2009).
Exosystems reflect the importance of the community in developing collective efficacy
(Cohen et al., 2006). For example, a British study, involving 268 mothers of young children at
high-risk of dental cavities found gaps in knowledge, and weak community and family
support regarding oral health (Blinkhorn et al., 2011). Yet health orientated social marketing
campaigns may challenge community social norms that the individual exists within.
Consequently, well intentioned interventions may produce resistance to change from the
targeted community.
Macrosystems represent the cultural context that the individual exists within, including
society’s cultural expectations of the individual. For example, a positive cultural belief
towards oral health can mitigate structural barriers, such as a lack of accessible transportation,

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school absence policies and discriminatory treatment (Kelly et al., 2005). However, this
assumes that the target audience are health literate, i.e. have the ability to understand and
comply with the required healthy behaviour (Nutbeam, 2000; Kickbusch et al., 2008). A lack
of health literacy has been identified as a significant barrier in educating a population to
undertake healthy behaviour changes (Nielsen-Bohlman et al., 2004).
3. Methodology
The aim of this paper is to investigate and explore how a SEM of social marketing
communications may achieve behaviour change. A reflexive, mixed methods case study
approach was used, which provides opportunities to examine the rich variety of primary and
secondary data collected, and to evaluate policies and interventions and their impact on inter-
related environmental influences affecting children’s oral health.
A triangulation of methods was employed, including documentary review, observation at
meetings, in-depth telephone interviews with those involved in developing Childsmile’s
social marketing communications strategy and a review of Childsmile’s use of findings from
a needs assessment (undertaken by the Institute for Social Marketing) and commissioned to
inform the development of its marketing communications campaign. Firstly, the documentary
review included Childsmile and Scottish Government’s oral health documents to assess policy
decisions and objectives, and internal Childsmile planning documents, processes and
monitoring data made accessible to the authors:
Insert Table 1 here
Secondly, supporting these documents, two members of the NHS Health Scotland/
Childsmile marketing communications team were interviewed twice. These interviews, using
open-ended questions, explored the planning and information-gathering, and its subsequent
use and delivery in Childsmile’s marketing communications. Thirdly, complimenting this,

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one of the authors observed key meetings to progress initial planning of Childsmile’s
marketing communications campaign allowing further insights into Childsmile’s programme
constraints and opportunities.
Finally, the needs assessment approach undertaken by the Institute for Social Marketing on
behalf of Childsmile was critically reviewed alongside Childsmile’s use of the findings, in
order to plan their social marketing communications strategy.
This needs assessment comprised18 stakeholder focus group interviews. The focus groups
aimed to identify core issues surrounding oral health care and related communications in
relation to young children from the perspective of parent/carers and professionals involved
with early years. Stokols (1992) argued that the premise of the SEM required understanding
of how target audiences interact with their environment, and focus groups were chosen as an
effective way to gain rich data and ‘real life’ understanding from a range of stakeholders,
within the research resources (Petty et al 2012). A topic guide, used to ensure coverage of key
issues, was developed from the research questions, a literature review including oral health
and behaviour change papers, and input from the programme steering group (refer to
Appendix 1). Respondents were also encouraged to raise any additional issues they thought
were relevant. Interviews were digitally-recorded with participants’ permission, transcribed in
full, annonymised and analysed thematically.
One set of focus group participants consisted of first time parents/main carers with one
child aged 0-3 years, or parents/main carers with more than one child who were eligible for
the nursery and school-based Childsmile programmes. The sample was drawn from lower
socio-economic groups (C2DE) living in disadvantaged areas in Scotland, reflecting key
targets. Ten focus groups were recruited (n=53, groups comprising 3-8 respondents each):
Insert Table 2 here

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Eight mini-focus groups representing professionals were also recruited consisting of
Childsmile oral health workers and other related health professionals such as Public Health
Nurses/Health Visitors and Midwives; and Nursery Staff:
Insert Table 3 here
Analysis of the triangulated case-study data used an evaluative approach. Rossi et al
(2004, p.28) describe this as an approach which uses "...social research methods to
systematically investigate the effectiveness of social intervention programmes.” Such an
evaluation requires an objective assessment and appraisal of the social marketing activity to
reach relevant conclusions for future research and programmes (World Health Organisation,
2001). This was achieved for this paper through applying Naidoo and Wills (2000) evaluation
criteria:
• Effectiveness – the extent to which the health promotions aims and objectives were met
• Appropriateness – how relevant was the intervention to the needs of the target audience
• Acceptability – was the promotion carried out in a sensitive, appropriate manner
• Efficiency – were time, money and resources used to maximum effect, and
• Equity – did the promotion have sufficient resources equal to the target audience needs
4. Findings
The findings are presented using Naidoo and Wills (2000) evaluation criteria outlined
above.
Effectiveness – the extent to which the health promotions aims and objectives were
met. The World Health Organisation (2001) argue that the evaluation of any marketing
communications campaign must commence with evaluating the clarity of the concept, i.e.
were the aims clearly expressed and were they met. This is particularly relevant to
Childsmile’s marketing communications and the SEM as it infers a response to the influences

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of: (i) the target population’s demographics, (ii) the nature of the environment that the
population exists within, such as their community and social networks, and (iii) how people
engage with various health related institutions (Brug, 2006).
Childsmile summarises its vision as combining targeted and universal approaches to
tackling children’s oral health improvement through the four programme components (Core,
Practice, Nursery and School) as mentioned above. Focussing on the communication strategy
the goal is ‘to drive uptake of Childsmile within each local Health Board, with a focus on the
early years’ (Moore et al, 2010).
Considering the environment’s effect on children’s oral health and Childsmile’s vision and
goals, Childsmile’s marketing communications addressed two themes: (i) the need to educate
parents about children’s oral health and Childsmile, and encourage early registration with a
dental practice, and (ii) the need to support dental practices and related professionals in
providing friendlier service encounters, and in encouraging oral health behaviours. Childsmile
developed a marketing communication campaign that addressed these themes whilst
addressing wider environmental influences identifiable with SEM. Table 4 describes the
marketing communications materials for the public and Table 5 materials for professionals:
Insert Table 4 here
Insert Table 5 here
Childsmile’s vision and objectives were a response to Scotland having one of the highest
rates of childhood dental decay in Europe, coupled with significant inequalities in oral health,
low rates of dental registration for young children (35% of 2 year olds in 2004), limited
preventative activity, and oral health problems being the most common reason for children to
have an elective general anaesthetic (Macpherson et al 2010).

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Indeed, although inequalities in oral health persist (Macpherson et al 2011), improvements in
children’s oral health are evident and, encouragingly, national targets calling for 60% of
school-aged children to be caries free by the year 2010 have been met. A national loner-term
assessment of Childsmile impact, led by Glasgow University will deliver further insights into
the effectiveness of the marketing communications, although the natural, roll-out of the
programme and resultant non-experimental study design will not afford assessment of the
unique contribution of Childsmile’s social marketing activity (over and above other
programme interventions).
Although assessment of more proximal measures is subject to the same cautions with
regard to attribution as longer-term health outcomes, it can be argued that shorter-term
outcomes (in terms of Childsmile’s over-arching theory of change) such as the number of
nurseries and schools participating in the programme, or the number of children enrolled at a
dental practice, provide a more timely measure of the communication strategy’s impact at this
relatively early stage of programme delivery. Childsmile monitoring activity provides some
support for the suggestion that the marketing communications programme is having some
success in engaging its target audience. In the period 2006-2010, the proportion of socially
deprived schools, (identified by the Scottish Index of Multiple Deprivation), participating in
the Childsmile tooth-brushing scheme increased from 52.7% (n=482) to 94.7% (n=540),
whilst the percentage of all nurseries participating remained around 94% during this period
(Childsmile Evaluation and Research Team, 2011). A similar improvement is the increase in
the number of children attending a Childsmile dental practice rising from 1,142 in 2006 to
28,164 by 2010 (Childsmile Evaluation and Research Team, 2011).
Appropriateness – how relevant was Childsmile’s marketing communications programme
to the social, institutional, and policy needs? In response to, Childsmile’s focus on socio-

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economically deprived communities, issues of empowerment, equity, inclusion, respect and
social justice within the SEM framework are considered.
Childsmile actively involved key social, institutional, and policy stakeholders in the
development of their marketing communications. This was achieved through a variety of
approaches, including: clinical guidelines and working with policy makers, previous
experiences of Scottish child orientated oral health programmes, and commissioning The
Institute for Social Marketing to undertake a needs assessment exercise to identify the target
audiences’ core issues surrounding oral health. This needs assessment comprised two
complimentary methods. First, secondary data identifying oral health problems amongst
Scottish children was collected and reviewed. Second, focus group interviews were
undertaken in order to facilitate stakeholder participation during Childsmile’s marketing
communications initial design stage. Focus groups were deemed appropriate for exploring the
views and shared experiences of participants. Importantly, this approach benefits from
respondents' interaction with one another as well as the moderator (Webb and Kevern, 2001),
promoting reflection on the experiences of particular services or activities, and generating
further insights and ideas for potential improvements, perhaps more than one-to-one
interviews may achieve.
The key findings from the first set of focus groups (first time parents/main carers) and how
the various SEM systems affected children’s oral health are presented below:
Insert Table 6 here
A key aspect of social marketing communications and their appropriateness is that the
communities Childsmile targeted experience the communication materials as empowering,
equitable, inclusive, respectful and offering social justice. The issues raised from these focus
groups were partially addressed through existing programme interventions, on a face-to-face
basis, through health professionals either in the parents’ home or other community venues,