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.
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Ethics come into play when an organization is deciding how to best serve their own needs while still fulfilling the obligations they owe to the stakeholders.
If these are established as the hypernorms for a research project, one must consider the implications of researching in other societies.
If a company has two factories, one in America, and one in Vietnam, they should be held to the same standard. Both tests begin with the simple question, “is our action legal?” The important part is that neither stops at this minimum standard, however.
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?). Where it is illegal to murder a person, a hypernorm would state that it is unethical to harm them at all.
Warren Keegan suggests that to serve the global community effectively, organizations “must practice corporate social responsibility,” defined as self-regulation to protect society (Keegan, 2013).
Cultural shifts must be accommodated when creating a metric for ethical behavior and consideration for that culture’s hypernorms must be made. While the two locations likely have different appeals to the company, either geographically or financially, the existence of a Vietnamese location should not serve only as a cost-cutting mechanism, but should also exist to better the lives of the workers. If this imperative is not met, not only will shareholders be at a loss, but so will employees and other businesses within the supply chain.
The Texas Instruments method is not as thorough as the Laczniak Test, but serves as a good starting block as an ethical test. 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 next step is to decide how to best address ethical issues which may arise in any facet of the business, from research to production to marketing and sales.
If, for example, an American company is doing business with a Laotian company and the manager learns that it is considered highly unethical in Laos to do research without explicit consent (while in America, they accept implicit consent), the American manager should find new research methods to abide this standard.
This form of corporate social responsibility would not only serve to further the economic goals of the corporation, but to also enhance the society around it by providing safe jobs to citizens in the area and by otherwise improving the area, thus serving all relevant stakeholders.
It can be easily modified to add other questions like “Does this action affect the environment adversely?” or “Is this practice beneficial for the local community?” The Laczniak Test is very thorough, covering multiple concerns, including legality, obligations, motives, and rights, among others. Managing business values in a globalized economy by isct (integrated social contract theory) - a comparative study.
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.
After these determinations have been made, a company can begin to build a set code of ethics. By combining the theories of Rousseau and Donaldson, the manager should be able to find an ethical solution to his dilemma.
Not only is this in the interest of common human courtesy, but good treatment of consumers can save an otherwise mediocre company and poor treatment of customers can destroy an otherwise brilliant company. As it is very thorough it is better suited to large-impact decisions, but impractical for everyday decisions.


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.
Treating the consumers fairly is the right thing to do by virtue, but the consequences otherwise are damning. 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. Salespeople must consider the customs of the area to which they are selling to be successful. 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. If it is a highly religious Christian area, not only will making calls on Sunday be unsuccessful, it will also be offensive. 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.
In some areas it would also be considered offensive to turn away a small gift, while in others it may be considered a bribe. 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! If a company is otherwise ethically perfect, but still dumps toxins in the river, they are harming the society as a whole.
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? The consequences of a company’s actions must be considered as part of their ethical footing. 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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