One foggy October night, a U.S. Naval Ship was sailing off the coast of Newfoundland. Seeing a light in the distance, the Captain of the ship called over the radio and said, “Please divert your course .5 degrees south to avoid a collision.” A voice came over the radio in reply, “We recommend you divert your course 15 degrees north to avoid a collision.” The Captain said again, “This is the Captain of a US Navy Ship. I say again, divert your course.” In defiance, the voice on the other line said, “No. I say again, you divert YOUR course.” Frustrated and angry, the Navy Captain said once again, “THIS IS A UNITED STATES AIRCRAFT CARRIER - WE ARE A LARGE WARSHIP OF THE US NAVY. DIVERT YOUR COURSE NOW!!” This time, he heard in reply, “We are a light house. It’s your call.”
Though the Navy has denied the veracity of this story, it has made its way around the internet and variations have appeared in publications like the #1 New York Times Bestseller Seven Habits of Highly Effective People by Steven Covey.
This simple story’s popularity can likely be attributed to the valuable lesson it conveys: sometimes it really is ‘us’ and not ‘them’. This lesson can be a useful one when developing social marketing projects. This paper draws on lessons learned from The National Social Marketing Centre’s (The NSMC) National Demonstration Site Scheme. The ten pilot projects provided clear examples of when behavior change needs to happen internally within an organization, before an external audience can be expected to “divert their course.”
The Traditional Approach: A View from the Bridge
There are many great examples where focusing on an external audience has lead to a successful behavior change. One such example is a project by the Injury Prevention Center in Dallas, Texas . They launched a social marketing program to increase the use of child car seats among the local Hispanic population. Through focus groups, the program team identified two key factors which prevented the target audience from using child restraints. The first was the fact that parents’ viewed themselves as good drivers, and therefore believed they were not very likely to have an accident. The second factor was the interplay of religion and fatalism among the target group. Many parents believed that if they were going to have an accident, it was “in God’s hands.” Therefore, they did not think a car seat would play a role in their child’s destiny.
In order to address this belief, the Injury Prevention Center partnered with local faith organizations to have priests bless the car seats, thus increasing their acceptability among the target population. The intervention operated in health centers, day care centers, neighbourhoods, and local schools in an effort to reach as many of the target audience as possible. Three years after the start of the program, use of car seats skyrocketed from 21% among Hispanic preschool aged children to 73%. By the sixth year, use had surpassed 85%.
A Different View: The Importance of Running a Tight Ship
As the example above shows, focusing on external audiences can often lead to the desired behavior change. However, this is not always the case; sometimes you have to focus your efforts on internal audiences.
In 2007, The NSMC set up a three-year pilot program called the Learning Demonstration Sites Scheme . Ten sites across England were chosen to receive support from The NSMC for the implementation of social marketing programs. No two sites were the same. Projects addressed a range of public health issues from underage kerbside drinking and fruit and vegetable consumption to breastfeeding and breast cancer.
Using the Key Insights
All projects followed The NSMC’s Total Process Planning framework . During the scoping stage, each project conducted primary research with their target audience and key stakeholders. Interestingly, researchers learned that – for many sites – the primary hindrance to the desired behavior change was actually due to internal as opposed to external issues. As is evidenced by the outcomes of the case studies below, it became clear that internal organizational systems within the National Health System (NHS) would have to change before certain behavioral goals would be met.
This article draws on three of the ten projects where the primary research highlighted internal issues. Two of the three case examples changed internal structures, while one did not.
Case Example #1: Me2 Stop Smoking Club
NHS Stoke-on-Trent (in the West Midlands, England) set out to reduce smoking rates during pregnancy among women in two high prevalence neighbourhoods. Focus groups were conducted with the target population. From this research, three key insights were identified:
- Smoking gave the women some much needed “me time” (time for themselves away from the children, as they often went outside or in a different room to smoke);
- While they already knew the harms of smoking, they did not like the judgmental and nagging tone of the health professionals who told them to quit; and
- Women noted that nurses would “talk to their bump” instead of addressing them directly.
NHS Stoke-on-Trent used these insights to reconfigure the existing smoking cessation service and introduced a new style of peer support group (named the Me2 Stop Smoking Club), which focused on rewarding mothers and giving them “me time”. For example, the women were taught to give each other hand massages and manicures whilst their children were looked after in the crèche.
Additionally, the stop smoking nurses were trained on how to engage with the women, what to say to encourage the women (and what not to say!). The pilot achieved a 60% quit rate (from quit date to 4 week quitter). By the end of 2007/2008, the service had delivered 121 4-week quitters, compared with 38 in 2006/2007.
Case Example #2: Breast Awareness Campaign
NHS Tameside and Glossop (an area in North West England) focused their project on breast cancer, as late diagnosis leads it to be the most common cause of death from cancer among women in that area. The large number of late diagnosed cases concerned and confused the NHS organization, as it was assumed that General Practitioners (GPs) and primary care nurses regularly talked to women about being breast aware when they visited their surgery. However, research with local women revealed that most women had in fact not been spoken to or offered any advice on breast awareness by their General Practitioner or nurse (even though the evidence suggested this was a very effective way of making women breast aware). Some other important insights arose from the scoping phase:
- Most women were registered with a GP;
- On the whole, women trusted and respected the local health professionals, and were more likely to change their behavior if asked to by their GP or nurse; and
- The women had a lack of know-how and were confused around the breast aware message – there was confusion if you should still regularly check your breasts, how to check/what to feel for, and so on.
In response to the research findings, NHS Tameside and Glossop developed a communications campaign (aimed at the women) and held a number of community events. However, despite the insights, no work was done with GPs and nurse’s to encourage them to talk to women about breast awareness and teach the women how to check their breasts.
There was a 40% awareness of the communications campaign and the community events were well attended. However, both failed to impact on the women’s actual behaviour. Training and work with health professionals had initially been planned, however this work was cancelled when the outbreak of swine flu meant that financial resources had to be allocated elsewhere.
Case Example #3: Are You Getting It?
From 2007 to 2008, existing data from the NHS Norfolk and Waveney Chlamydia Screening Program (a rural area in the East of England) revealed that just 3.8% of young people in the area were screened for chlamydia. This was especially problematic, given the fact that the national target was 25%. At the time, the screening program was delivered by over 200 health and community screening providers across Norfolk and Waveney. However many of them returned few or no screens at all.
Research was conducted with a sample of the existing screening providers to try and understand why this was the case. A number of key insights were revealed, including:
- Low awareness of screening targets, which in turn led to a low prioritization of screenings;
- A perceived lack of support from the Chlamydia Screening Office (it was perceived that they only contacted the providers to “tell them off” if forms were not completed correctly); and
- A lack of confidence to talk to the young people about sex, if they were being seen for another medical issue (for example, a broken leg – GPs were unclear how they could start a conversation about screening).
Six interventions were subsequently developed. Instead of focusing on young people at risk of contracting chlamydia, all of the interventions targeted service providers in order to increase screening activity within screening sites. The interventions also focused on enhancing the Chlamydia Screening Office’s role in engaging, supporting and managing the large and growing number of screening venues.
The chlamydia screening rates among 15 – 24 year olds subsequently increased from 3.8% to 16.15%.
Key Lessons and Conclusions:
It can be extremely uncomfortable when the scoping research identifies internal problems as being the key barriers to achieving the desired behaviour change. Especially if the internal barriers are caused by the ones commissioning you!
Initially, when the research findings indicated internal issues, some of the project teams involved with the demonstration sites became defensive and concluded that the research “must be wrong”.
This led to a difficult decision being made by The NSMC team – do you back down and allow the local team to do what they had wanted to do in the first place – a campaign aimed at an external audience – or do you persevere and push for internal changes to be made?
Internal organizational change can often be more difficult than external behavioral change, because key stakeholders are forced to look internally, identify faults and barriers with the current situation, and then change attitudes, policies and practices, which are frequently ingrained and institutionalized – especially in huge bodies such as the NHS. However, as the case examples show, sometimes addressing the behavior of people within the organization is the most effective way of achieving your desired behavior change. Recognizing this fact will help organizations avoid the ‘Lighthouse Effect’ and instead develop programs and policies that will be effective.
1) The case study, and all the other case studies in this article, are available in full on The NSMC’s ShowCase. www.thensmc.com/resources/showcase
2) Details of the scheme can be found at: www.thensmc.com/content/learning-demonstration-sites
3) Details of the Total Process Planning framework can be found at: http://socialmarketing-toolbox.com/