In other words, the theory you use – whether old, new or personal – frames the way you look at a problem, try to understand it, go about solving it and attempt to measure it (for example, not one epidemiological survey has ever give me a clue about HOW to change risk behaviors, only that it needed to be done for certain population groups).I was recently called into a family planning project at the beginning (thankfully) to help develop an overall approach and strategy.
Research should target practices, social factors and behaviors that fuel HIV epidemics across populations and settings. Work with Community-Based Organizations (CBOs) and Health Departments (HDs) to determine how best to focus and tailor these responses in their particular communities.
Research should focus on the process of dissemination that emphasizes studies of training procedures, end-user response to guidance, implementation strategies, contract manager effectiveness, enhancers and barriers to scale up, evidence in the real world for effectiveness, and capacity building.
CDC should undertake a community-driven research agenda that takes advantage of its unique relationships with CBOs and HDs and encourages their input in the identification of emerging issues and potentially effective practice-based interventions. Social marketing has a central role to play in scaling up interventions and in research-to-practice strategies. Audiences need to be broadened from at-risk populations and service providers to include DOH and CBO implementation agents (for example, Learning from the Community: What Community-Based Organizations Say About Factors that Affect HIV Prevention Programs -pdf). Theoretical models that drive program development, implementation and evaluation do not reflect a unified conceptualization of behavior change. After a number of posts about the need for more radical behavioral research in HIV prevention and to scale up demonstrably effective programs for HIV prevention, it was an honor and privilege to serve on the DHAP review team and to part of a very knowledgeable, dedicated and fun panel. Gaining insight into why programs achieve scale or not is not sufficient for change at any level of society. The Bringing HIV Prevention to Scale report also examined how the successful national efforts of Brazil, Senegal, Thailand and Uganda scaled up their national HIV prevention activities.
The report also highlights that truly comprehensive HIV prevention programs need to focus on (1) preventing sexual transmission, (2) preventing blood-bourne transmission (including through blood transfusions and sharing injection equipment), (3) preventing mother-to-child transmission, and (4) social strategies and supportive policies. Reading these reviews I have to ask if this problem of scale is really a call for better social marketing - creating and managing markets and resources more strategically?
Then again, I guess we could be talking about marketing through social network sites and blogs? About the image: This map shows the distribution of all people between ages of 15 and 49 with HIV.
Scaling up programs that have been shown to be effective in promoting health and other social causes in pilot and demonstration projects or larger efficacy and effectiveness trials should be a major focus of social marketers. Though numerous examples abound to support this conclusion, I will focus on one: HIV prevention programs.
Despite the extraordinary potential of available prevention strategies, most people at risk of HIV infection have little or no access to basic prevention tools. Among the factors the Working Group identifies as fueling the failure to scale HIV prevention efforts are:Inadequate Financing. Our challenge, whether it be in HIV prevention or the prevention of childhood obesity, it to apply the evidence-base of diffusion research through social marketing programs.
In developing countries, social marketers have been trying to get more people to use condoms. Since 2003, according to a PSI survey, young men and women in Kenya with multiple partners increased their use of condoms from 33 to 47 percent. Blog that publishes text and some graphics on topics related to social marketing and social change issues. Intervention strategies targeting the individual level include goal setting, behavioral contracting, and tailored health communication. Insights into Inspiring Behavior ChangeInspiring people to change their behaviors in order to become healthier remains one of the most intractable challenges. This environmental scan, Transforming Bodies and Lifestyles: Insights into Inspiring Behavior Change, identifies key strategies that stakeholders throughout the global health economy can use to help people make lasting changes that promote long-term health.
Some examples include:For behavior change to be successful, information needs to be targeted to individuals based on their contextual needs.
Developed to compliment our 2010 map on the Future of Science, Technology and Well-Being, this scan points you toward things you can begin doing today to inspire behavior change in the long run. In the fifth installment of HC3’s Innovation in Health Communication Webinar series, the presenters focused on defining BE and how it interacts with the field of social and behavior change communication (SBCC).
Ellie Turner, Program Manager for the Behavioral Economics in Reproductive Health Initiative (BERI) at the Center for Effective Global Action (CEGA) at UC Berkeley, asked the audience to look at non-market-driven factors. Turner also shared that BERI will be releasing a white paper in the near future that features a framework to help identify challenges that may be ripe for interventions.
The session concluded with a short Q&A session and closing remarks by Marcie Cook, Regional Director of Asia and Eastern Europe at PSI. The complete list of speaker presentations along with the recorded webinar is listed in the HC3 Project Materials section.
Let us know on the Health Communication Innovation Webinar Series group on Springboard for Health Communication, a new social network for health communication professionals. Subscribe to Blog via Email Enter your email address to subscribe to this blog and receive notifications of new posts by email. This website is made possible by the support of the American People through the United States Agency for International Development (USAID).
While learning about the theories was repetitive, I felt like I learned a more useful way to apply them to interventions. While I cannot predict what the final report might look like, or how CDC may choose to implement the recommendations of our panel and from the other four, hopefully you will find a new idea or inspiration in these recommendations to improve your ability to design public health change. Learning how programs successfully achieve scale (what some might call observational learning), imitating them (a form of flattery that many are loathe to practice unfortunately) and monitoring performance (through relevant program outputs and behavioral outcomes to feed back to planners what is working and what needs to be adapted to local circumstances) are the components of turning lessons learned into action (note I deliberately left out epidemiological endpoints. These countries have demonstrated that it is feasible to reduce the incidence and prevalence of HIV, slow down the rate of predicted increases in prevalence and keep HIV infection rates at low levels. These authors also note that expanding access to key HIV prevention services including HIV counseling and testing, expanding condom distribution and use, and targeting of high risk and vulnerable groups - injection drug users, sex workers and men who have sex with men - are all necessary for scaled up programs to succeed.
Or has the international health community gotten to the point where social marketing is being marginalized as a term reserved only for the promotion and distribution of subsidized commodities through commercial sector channels? I say 'should be' for while we talk about population-based or social change, the fact is that few evidence-based practices ever achieve the scale necessary to make their promise or vision reality for the thousands or millions of people who could benefit from them.

The Global HIV Prevention Working Group has just released a report on the 'failure to scale' (my words, not theirs).
Although necessary coverage levels vary depending on national circumstances, current coverage levels for essential prevention strategies are woefully inadequate for any national epidemic.
Only 9% of risky sex acts worldwide are undertaken while using a condom, and the global supply of condoms is millions short of what is needed. In the most heavily affected countries of sub-Saharan Africa, only 12% of men and 10% of women know their HIV status. It is estimated that fewer than 20% of people with a sexually transmitted infection are able to obtain treatment, even though untreated STIs increase the risk of HIV acquisition and transmission by several orders of magnitude.
Years after clinical trials demonstrated that a brief, inexpensive antiretroviral regimen could reduce the risk of mother-to-child HIV transmission by 50% (5), only 11% of HIV-infected pregnant women in low- and middle-income countries receive antiretroviral prophylaxis. Prevention services reach only 9% of men who have sex with men, 8% of injection drug users, and under 20% of sex workers.
An estimated 6 million units of unscreened blood are transfused yearly in developing countries, and 40% of injections administered in health care settings are unsafe. While financing for HIV has increased dramatically in recent years, available funding is only slightly more than half of amounts needed to support a comprehensive, scaled-up response. Several impediments stand in the way of doing so, not the least of which is the overwhelming (at least to me) lack of understanding among health professionals and policy makers of what this research offers health and social programs (other than fleeting references to The Tipping Point). But the United Nations Development Program says that breaks down to about 10 condoms a year for every man in Africa — and that is not enough. Problem is that two of the four major networks (CBS and FOX) rejected the TV ads for not focusing on preventing diseases (which diseases do the ED drugs prevent again?). Some people may not be ready to attempt changes, while others may have already begun implementing changes in their smoking, diet, activity levels, and so on. Interventions to Change Health Behavior Health behaviors are shaped through a complex interplay of determinants at different levels. These strategies most typically draw on Social Cognitive Theory (SCT) and the Stages of Change construct from the Transtheoretical Model. It takes a broad look at emerging theories of motivation to identify key insights in the form of opportunities to intervene to change unhealthy behaviors and enable people to build capacities to create health and well-being in their own lives. Luckily, technological advances from smart phone apps, sensor networks, and the Internet of Things are making it easier for individuals to receive targeted, contextually relevant feedback that connects them to relevant resources in their Personal Health Ecology. By identifying, understanding and tackling the behavioral factors that prevent development programs from being as successful as they could be, BE can help improve program implementation. The session was moderated by John Strand, Director of Social Marketing and Communication at FHI 360. Saugato Datta, Vice President at Ideas42 introduced Ideas42 and how it uses BE to define, diagnose, design and test solutions for development programs.
Robertson brought key insights as to how BE relates to SBCC, including the importance of examining not only what influences decision-making but also what influences action to better design interventions. She noted that a lot of programs address “market failures” – access, cost, information, supply workforce – but BERI looks beyond these to see the non-market-driven factors that prevent individuals from acting in their best self-interest in reproductive health decisions.
Cook emphasized the benefits of leveraging this mulch-disciplinary approach to look at SBCC through a different lens. The Health Communication Capacity Collaborative (HC3) is supported by USAID's Office of Population and Reproductive Health, Bureau for Global Health, under Cooperative Agreement #AID-OAA-A-12-00058. This is, what the student above referred to, as theory from the 1950s (well, not quite that long ago, but you get the idea). The total DHAP budget in FY2009 was $853 million, of which $28 million (that’s 3.2%!) was for behavioral intervention research.
The second is that very few social marketers seem to know how to transform programs focused on individual behavior change to ones scaled for population impact. The construct of “stage of change” is a key element of The Transtheoretical Model (TTM) of behavior change, and proposes that people are at different stages of readiness to adopt healthful behaviors. For example, physical activity is influenced by self-efficacy at the individual level, social support from family and friends at the interpersonal level, and perceptions of crime and safety at the community level.
Social Cognitive Theory (SCT) explains human behavior in terms of a three-way, dynamic, reciprocal model in which personal factors, environmental influences, and behavior continually interact. Fifty-percent of all deaths each year are the result of potentially preventable chronic diseases such as heart disease—costing hundreds of billions of dollars annually. It also identifies critical emerging technologies that will shape our everyday health experiences. Improvements in how “real” virtual reality simulations can be, and how immersively they can engage all human senses, allow us to more effectively visualize and experience the benefits of making changes that have an immediate cost plus a delayed benefit that won’t be experienced in the real world for many years—a circumstance that has historically been a real barrier for sustained motivation.
Examples from health programs in Ghana, Indonesia, Kenya, Malawi and the Philippines were cited. Behavioral economics can inform our understanding of decision-making, which is integral to program design. HC3 is based at the Johns Hopkins Bloomberg School of Public Health's Center for Communication Programs (CCP). It is the canon for behavior change academics, one that must (?) be passed down to the graduate students of today for it’s historical importance – although, unfortunately, most of those instructors I expect still believe it to be operational.
It proved to be a daunting task, especially since the last full programmatic review was in 1993. What impressed me (and others on the panel) was how this limited budget was spent on mimicking a drug R&D process of uncovering the most effective elements of HIV prevention programs, testing them, packaging them and then promoting their availability to the community. In part due to the weakness of HIV information systems, many countries do not target limited funds where they would have the greatest impact.
Even fewer researchers and their funders seem to get that developing and testing programs meant to achieve scale need to be designed that way to begin with and not focused on reductionistic minutiae that - again - focuses on individuals, not people.
The notion of readiness to change, or stage of change, has been examined in health behavior research and found useful in explaining and predicting changes for a variety of behaviors including smoking, physical activity, and eating habits.
Key constructs of social cognitive theory that are relevant to behavior change interventions include observational learning, reinforcement, self-control, and self-efficacy.

To address these and other challenges, behavior change efforts will be central to shaping the future of health and health care.
Combining insights from the social sciences and technology creates new opportunities to deliver more persuasive, personalized, and meaningful messages to promote healthier behaviors.
Cutting edge studies of the way social networks work is showing that you can change attitudes, weight, and other factors of individuals just by inducing changes in some of the key people around them. Datta said BE can be used to design interventions that facilitate the making of decisions, such as those related to service delivery, like when a provider chooses about what family planning options to provide or highlight. Robertson closed by noting Melinda Gates’ article from earlier this year on reducing newborn deaths, which illustrated the importance of finding out what cultural norms or other circumstances may be working against SBCC programs, and added that an enabling environment is important to make BE work.
There was limited attention to what one panel member referred to as ‘the science of the street’ or learning from what is working in communities. Misallocation of limited resources by donors and affected countries also often occurs as a result of ideological, non-scientific restrictions imposed by donors on how HIV prevention assistance may be used.Capacity Limitations. And finally, as the Working Group makes clear, and as an old saying goes (thanks to Thomas Friedman): A vision without resources is just an hallucination. For example, social support for exercise from co-workers may interact with the availability of exercise equipment at the worksite to lead to increased physical activity. In the future, we’ll understand how to most cost-effectively target only a small number of people at the center of social networks for behavior change, and from there create changes that ripple through societal networks and result in significant aggregate change at the level of the city, state, or the country. But it can also be used for following through on decisions; for example, bridging intention-action gaps, such as those that prevent women’s fertility choices from being realized.
When I have done research into what theories people use in public health programs, practitioners can describe (maybe) one or two, and academics describe their own (developing your own theory must be a prerequisite for tenure now).
However, among the practitioners I have worked with, they find it a very useful and comprehensible road map for thinking about a variety of public health problems. Indeed, these activities were labeled ‘homegrown’ solutions and had little weight or prominence in the Diffusion of Effective Behavioral Interventions (DEBI) model. Due to inadequate human capacity, countries often have difficulty programming substantial infusions of new funding.Service Fragmentation. Traditionally, and especially in clinical settings, strategies to change health behaviors have focused on individual-level factors such as knowledge, beliefs, and skills. Together, these insights from social science and technology point toward new strategies you can use in your work today to develop and enhance your long-term behavior change initiatives.
Government information and does not necessarily represent the views or positions of USAID, the United States Government, or The Johns Hopkins University.
That some authors want to impose a single theory on social marketers borders on malpractice.People in the advertising and public relations worlds who work on social marketing projects don’t even know what a theory is – unless they have been in the game for a while. The integrative theory incorporates elements of 3 widely used theories in behavior change and communication interventions: the health belief model, social cognitive theory and theory of reasoned action.
The panel concurred that focusing such a small budget on the full spectrum of R&D activities was not practical or effective.
HIV prevention has frequently not been integrated into schools, workplaces, and other institutions, and HIV efforts are insufficiently linked with other health-related service systems, such as TB or sexual and reproductive health.Stigma and Discrimination. As ecological thinking has gained currency, intervention strategies have broadened to target factors at other levels of influence such as organizational policies and the built environment.
They want you to believe that their past ‘experiences’ give them a better feel for what will work with an audience than any textbook. In this model, whether a specific behavior is performed depends upon (1) if one intends to engage in that behavior - which you can see depends on a whole lot of things, (2) if they have the requisite skills and abilities to perform the behavior, and (3) if there are no environmental constraints (broadly defined) to performing the behavior. Rather, we suggested more of the CDC behavioral research endeavor should focus on the improving the science at the ends of the spectrum – innovation (often gleaned from communities) and dissemination (how to achieve scale for effective programs). The stigma associated with HIV and with membership in a vulnerable group deters many at-risk people from seeking HIV prevention services or learning their HIV status and also discourages the kind of political leadership required to implement a robust and evidence-based HIV prevention effort. This recognition of the complex range of factors that shape health behaviors can make the selection of intervention strategies daunting. What they often fail to intuit is that these ‘experiences’ form their own naive or folk psychological theories. We threw around phrases such as ‘community-driven research’ and ‘community-to-science’ to reinforce our point. Among the constraints identified in the audience research are the few facilities available in rural counties, busy clinic staff that makes local outreach and promotion efforts difficult, making time in their busy schedules for setting clinic appointments, and difficulties using the centralized referral service.Second, we need to assess if the person has the necessary skills to access and effectively use family planning methods over time. We asked: How about establishing an Innovations Lab for behavioral change research for HIV prevention to respond to emerging needs through formative research and Phase 1 studies and leave Phase 2 and 3 work to other agencies (NIH, HRSA, SAMHSA) to fund?
About several dozen to several thousand research studies validating them (and some will still argue ‘what do the researchers know! Among the determinants of these intentions we found that conservative community values can play an important role in reducing conversations and public education activities around family planning. Looking at the CDC as an institution, we were also asking ourselves quite often: What are the rewards and incentives for staff who conduct innovative behavioral research and dissemination of practices? We did not hear much about women believing they were not susceptible to becoming pregnant (though other research informs us that this is the most common reason from women to discontinue using contraceptives).
There was also evidence that women do talk with each other about birth control, though no common times or places were discovered that might guide communication strategy. Now some people will ask ‘what about…?’ And if you think that’s an important variable to consider, first make sure your audience does too.
While I am not going to defend this particular theory as all-encompassing (that is why there will be a second installment to this topic), what you can take away from this is: the theory you use helps you to focus in thinking about the issue, asking relevant questions of your audience and forming program strategies that are both theoretically- and research-driven.

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