Are social marketing campaigns effective in preventing child abuse and neglect?
Child maltreatment continues to be a significant social problem in Australia and many other nations. The best available data suggest that between the ages of 0-18 years: 5-10% of children experience physical abuse; around one-in-ten are emotionally maltreated; 12-23% witness family violence; and 4-8% experience serious (i.e., penetrative) sexual abuse (Price-Robertson, Bromfield, & Vassallo, 2010). There were 55,000 cases of child abuse or neglect investigated and confirmed by child protection services in Australia in 2008-09 (Australian Institute of Health and Welfare [AIHW], 2010).
Media-based social marketing campaigns have been identified by the World Health Organisation as having the potential to contribute to the prevention of child maltreatment (World Health Organization [WHO], 2006). Social marketing involves the application of commercial marketing techniques and technologies to "influence the voluntary behaviour of target audiences to improve their personal welfare and that of society" (Andreasen, 1994, p. 110). A media-based social marketing campaign could contribute to the prevention of child maltreatment by raising public awareness of the issue and educating and fostering pro-social behaviours within families.
This Issues paper presents the results of a systematic review of literature about social marketing campaigns related to the prevention of child abuse and neglect, and to parenting problems. The paper aims to identify the characteristics of campaigns in this area and the evidence regarding their effectiveness.
What is social marketing?
Social marketing differs from other branches of marketing in that it relates to the wellbeing of the community (rather than the wellbeing of the marketer) (Donovan, 2005). The fundamental goal of social marketing campaigns is to bring about behavioural change (Andreasen, 2003). This can range from encouraging people to change a specific behaviour on their own (self-regulation) to seeking professional help about a difficult problem. Social marketing draws from a broad range of social sciences for the purpose of influencing people in socially desirable ways and generating social good (Donovan & Henley, 2003; Stead, Gordon, Angus, & McDermott, 2007).
Social marketing campaigns are generally categorised according to whether they appeal to positive motivations and emotions in order to bring about the desired behavioural change (referred to as "incentive appeals") or whether they rely upon fear to bring about the desired behavioural change (referred to as "threat appeals") (Henley, Donovan, & Moorhead, 1998; Henley & Donovan, 1999).
It has been proposed that effective social marketing include strategies that target change in social environments, communities, social policies and legislation, rather than solely relying on individuals to change their behaviour (Donovan & Henley, 2003; Siegel & Doner, 1998). For example, the Ottawa Charter for Health Promotion (WHO, 1986) and more recently, the Bangkok Charter for Health Promotion in a Globalised World (WHO, 2005) recommended that contemporary public health social marketing campaigns invest in the social and environmental determinants of health and welfare, stating that: "people cannot achieve their fullest health potential unless they are able to take control of those things which determine their health" (WHO, 1986). According to Donovan and Henley (2003) a social marketing campaign that targets social structures will be more likely to produce a "social good" (p. 6).
Although social marketing campaigns aspire to achieve social good there can be potential for unintended harm to occur (Donovan, Jalleh, Fielder, & Ouschan, 2009). For example, there has been concern from some sectors that social marketing campaigns with "hard-hitting" content (i.e., graphic, emotive and/or shocking content) can be damaging in certain contexts. As an illustration, a media campaign that was intended to reduce violence against women and featured depictions of gratuitous violence was criticised for being potentially counter productive (i.e., promoting violence rather than discouraging it) (Donovan et al., 2009, p. 7). Social marketing campaigns that utilise hard-hitting content to address child sexual abuse are especially fraught, as they have the potential to expose children to traumatic themes and images and re-traumatise child sexual abuse survivors (Australian Centre for the Study of Sexual Assault [ACSSA], 2010). Social marketing campaigns with hard-hitting content have been the subject of heated debate in Australia (Donovan et al., 2009; ACSSA, 2010).
Public health and law enforcement are the main fields that have conducted social marketing campaigns in Australia. Social marketing emerged during the 1970s as a strategy to communicate messages about social issues, with topics related to hygiene, family planning and attitudes towards women (Donovan & Henley, 2003). During the 1980s, social marketing in Australia became established as an approach to educate the public and target individual behaviours. Social marketing campaigns at this time targeted drink-driving, heart disease prevention, and increased use of car seatbelts. By the 1990s health-related behaviours dominated the Australian social marketing field, such as Quit campaigns (anti-smoking) and the famous "Grim Reaper" advertising (HIV/AIDS) (Rigby, Brown, Anagnostou, Ross, & Rosser, 1989; Scollo & Winstanley, 2008). Social marketing campaigns related to child maltreatment are one of many competing for public attention in a crowded media environment (Randolf & Viswanath, 2004).
Advertising is a core element of social marketing and is most useful where there is a lack of awareness about a social issue. One of the benefits of social marketing campaigns that include a mass media advertising component is that they are likely to increase public awareness, irrespective of the specific aims of the campaign. It has been argued, however, that advertising alone is not as effective in bringing about population-wide changes as a social marketing campaign that is incorporated with a broader set of intervention strategies (Wise, 2000). According to this perspective a social marketing campaign that includes, for example, advertising and a community-capacity building component or advertising and the provision of practical support is likely to be more effective at bringing about population-wide changes than an advertising campaign alone.
The public health model and social marketing targeting child maltreatment
Tertiary child protection services in Australia struggle to meet the needs of children in need of statutory intervention as well as the needs of children and families who are below the threshold for child protection intervention (O'Donnell, Scott, & Stanley, 2008). The National Framework for Protecting Australia's Children (Council of Australian Governments, 2009) recognises the current challenges for statutory child protection services and has a strong focus on prevention, operationalised through an adoption of a public health approach to preventing child abuse and neglect. In a public health approach, statutory child protection services are a last resort (tertiary intervention), with the bulk of support for families served by universal health and welfare services (primary prevention). Additional services are then provided for more complex concerns (secondary prevention). Interventions for issues such as parental substance misuse or mental illness, also act as sites for early intervention and prevention of child abuse (O'Donnell et al., 2008).
A public health approach to child protection interventions also provides a useful model for social marketing campaigns that intend to address child maltreatment and parenting issues (Allen Consulting Group, 2009; Tomison & Poole, 2000). In a public health approach, universal social marketing campaigns that target the whole community or all families are a form of primary intervention. These interventions support the safety and wellbeing of all children. An example of this would be a mass media campaign targeting parents and other adults to be aware that they are modelling alcohol-related behaviour to children when drinking alcohol in their presence. Secondary level social marketing interventions can seek to address risk factors to prevent child maltreatment and escalation of parenting problems, for example, a campaign about how risky alcohol consumption (e.g., binge drinking) can negatively impact the quality of parenting while intoxicated and/or hungover. A social marketing campaign can be designed as a tertiary intervention for the purpose of reducing harm to children and preventing the recurrence of maltreatment, for example, a campaign that aims to educate drink-driving offenders with child passengers of the harm to children if they are in a collision. It is also possible for a social marketing campaign to combine more than one type of intervention.
Developing a social marketing campaign
A range of theories and approaches could inform the development of a social marketing campaign. A public health approach can inform the decision regarding the target audience (e.g., primary, secondary or tertiary intervention) and health promotion theory can also be used to inform the way in which a social marketing campaign is developed and implemented. When considering the key steps involved in a social marketing campaign the Precede-Proceed model is especially useful. Developed by Green and Kreuter (2005) in the 1990s and updated in 2005, the Precede-Proceed model proposes that health promotion interventions should be multi-dimensional and participatory at an individual and/or community level in order to be effective (Lin, Smith, & Fawkes, 2007).
The Precede-Proceed model has four sequential stages:
- Assessing the needs of the population - assessing the social, environmental, educational and policy contexts behind the social issue, drawing on demographic information and knowledge of community needs and priorities to assess the needs of the population (DiClemente, Crosby, & Kegler, 2009; Lin et al., 2007);
- Selection of an appropriate theory - theories of individual and community change provide the logic for designing a social marketing campaign, guiding the definition of the social problem, planning a solution, implementing and evaluating the campaign (Nutbeam & Harris, 2004);
- Implementation - implementing the program as planned utilising the strategies deemed appropriate to the program objectives (Nutbeam & Harris, 2004); and
- Evaluation - assessing whether the campaign has been effective and whether it should be continued, modified or discontinued (Egger, Spark, & Donovan, 2005).
In the following sections the final three stages of the Precede-Proceed model are explored (selecting an appropriate theory, implementation and evaluation) in order to illustrate the stages involved in the development of a social marketing campaign and the models that could be used to guide social marketers through these stages. (The first stage, the special issue of child maltreatment, has been addressed above.)
Selecting an appropriate theory
One or more theories of individual or community-level change could be selected to inform the design of a social marketing campaign. This section presents the main theories for generating individual and community-level change that are commonly applied to social marketing campaigns (see Table 1 below).
Note: The information in this table was adapted from the following sources: Baum (1998); DiClemente et al. (2009); Lin et al. (2007); Noar (2005-2006); Nutbeam & Harris (2004).
The theories of individual change in Table 1 assume that awareness, knowledge and attitudes influence a person's behaviour (Nutbeam & Harris, 2004). Persuading an individual to change their behaviour relies on their self-efficacy to identify, make and sustain behaviour change. There is an assumption that there will be social gains for individuals who do change their behaviour, such as approval from others and peer acceptance (Nutbeam & Harris, 2004). A social marketing campaign based on individual change is relatively easy to implement and evaluate compared to community-based social marketing. Social marketing that targets community-level change includes more variables, making empirical evaluation more difficult to control (Nutbeam & Harris, 2004).
Implementing a social marketing campaign
There are a number of models that could be used to guide the implementation of a social marketing campaign. The two most influential models are the Four P's marketing mix (Andreasen, 1994) and the Communication-Persuasion Matrix (McGuire, 2001). These models are derived from commercial marketing. Each is briefly described below.
The Four Ps
The Four Ps is an approach to planning and implementing a social marketing campaign adopted from commercial marketing (Grier & Bryant, 2005). The marketing elements of product, price, place and promotion form a marketing campaign strategy (Andreasen, 1994). Some of the elements of the Four Ps approach are similar to the Precede-Proceed model. For example, the Four Ps model suggests that the product (i.e., the behaviour being promoted) should be responsive to the needs and wants of the target audience in the same way the Precede-Proceed model highlights the importance of assessing the needs of the population. A product should offer a solution to the social problem. The place is where the desired behaviour is put into action (Grier & Bryant, 2005). The place where the behaviour is performed needs to be accessible and convenient for the target audience. The price is comprised of social, psychological and economic costs and benefits to the individual engaging in the behaviour. Finally, the product of the campaign needs to be visibly promoted through media or other activities to reach the target audience. This requires a promotion strategy that is compatible with the lifestyle and personal preferences of the audience (Andreasen, 1994).
The Communication-Persuasion Matrix
The Communication-Persuasion Matrix (known also as the Communication-Behaviour Change Model) was developed by McGuire (2001) to guide the development of public education campaigns. It comprises five "input" communication variables:
- source - the person, group or organisation delivering the campaign message (e.g., government, non-government organisation);
- message of the campaign - including content, tone and form;
- channel through which the campaign is delivered, usually involving mass media;
- receiver or intended audience for the campaign (requires knowing social and demographic variables, current attitudes and behaviour and media preferences); and
- destination - the intended short-term and long-term outcomes of the campaign, such as specific changes in awareness, attitudes and behaviour (McGuire, 2001; McGuire, 1981; Nutbeam & Harris, 2004).
The Communication-Persuasion Matrix provides a model for implementing social marketing strategies, such as: what the message of the campaign should be, what tone the message should take (e.g., hard-hitting or a positive message) and which medium should be used.
Evaluating social marketing campaigns
In the context of social marketing campaigns about child maltreatment, evaluation is important because it can determine whether social marketing campaigns contribute to a reduction in child maltreatment and child abuse and, if so, how they can do so in the most effective way. Without embedding evaluation into the design of a campaign, it is difficult to determine if it has achieved any positive impact on the entrenched social problem of child maltreatment.
It is important to note however, that empirical evaluation of social marketing campaigns is challenging. A lack of access to expertise, technology and resources can impinge upon evaluation efforts. Evaluation can be perceived as diverting precious funds away from an intervention that is supposed to help people, meaning that there can be some reluctance to spend money designing and implementing an evaluation strategy (Tomison, 2000). There may not be the resources for rigorous experimental or quasi-experimental designs across the population that is exposed to the campaign. It is also difficult to isolate the impact of the campaign when there may be other factors influencing the community's attitude about child maltreatment. For example, a highly publicised fatal child maltreatment incident that occurs at the same time a social marketing campaign about child maltreatment is underway could impact upon people's attitudes about child maltreatment.
Systematic evaluation of social marketing campaigns is important, however, as it can provide insight into whether these campaigns are effective. Evaluation evidence is critical to justify the economic costs of a social marketing campaign and, most importantly, to ensure that unintended negative impacts have not occurred and there have actually been positive gains (Grier & Bryant, 2005). Evaluations of social marketing campaigns can also be used to build an evidence base regarding intervention effectiveness, and thereby have the potential to inform future campaigns and influence evidence-informed policy (Greir & Bryant, 2005; Nutbeam & Harris, 2004).
Box 1: Evaluation of social marketing campaigns
There are five main types of evaluation that can be used to evaluate social marketing campaigns (Bauman, 2000; Donovan & Henley, 2003; Hornik, 2002a; Noar, 2006; Nutbeam & Bauman; 2006; Valente, 2001). The types of evaluation reflect the stages of the Precede-Proceed model. These can be used to evaluate specific stages of a social marketing campaign, from design, through to implementation and campaign outcomes.
- Formative assessment determines the need for a social marketing campaign in a population. This can involve determining the social problem to be addressed, what the needs of the population are and what type of intervention would be most appropriate for the population. At this stage, a baseline population survey of the community is typically conducted for later comparison with a post-campaign survey.
- Pilot (or efficacy) testing is a trial of the social marketing campaign on a sample audience, often to determine if an intervention meets face validity. One of the benefits of pilot testing is that it provides an opportunity to adjust the campaign materials based on feedback from the participants.
- Process evaluation evaluates the implementation and dissemination of the campaign. This focuses on the degree to which the campaign was conducted as planned.
- Impact evaluation measures the direct, short-term effects of the campaign. This could include measures of mass media exposure and changes in awareness, knowledge or behaviour in the target audience.
- Outcome evaluation estimates the long-term effects, if any, associated with the campaign at a population level. This can include cost-benefit analysis. Examples of relevant outcomes include changes in prevalence or incidence rates, ongoing trends in help-seeking behaviour and sustained improvements in awareness, knowledge or behaviour.
Identifying child maltreatment social marketing campaigns
For this NCPC Issues paper, we undertook a systematic literature review to determine whether there was evidence that social marketing campaigns were effective in preventing child maltreatment. In a systematic review, sets of key terms or subject words are used to identify publications in academic databases and websites. The findings are then analysed to form an evidence-base (Petticrew & Roberts, 2006). By using a disciplined, replicable method for searching the literature and synthesising results, systematic literature reviews offer a transparent and reliable account of the current evidence (Littell, Corcoran, & Pillai, 2008). The aims of this systematic review were to:
- identify social marketing, media or community education campaigns in the area of child abuse and neglect or parenting problems;
- determine the characteristics (including notable strengths and limitations) of social marketing campaigns targeting child abuse and neglect and the factors that are known to contribute to the risk of abuse and neglect occurring (e.g., parenting problems, parental substance misuse, domestic violence in families and the impact of these on children) (referred to as child maltreatment campaigns);
- examine whether social marketing campaigns targeting child maltreatment had an effective impact on the awareness, knowledge, attitudes or behaviours perpetuating the social problem that they were designed to address; and
- draw conclusions about the usefulness and potential effectiveness of social marketing campaigns for child abuse and neglect prevention in Australia.
Literature searching was conducted between August and December of 2009. For a full description of the search strategy for identifying literature for this paper, including databases searched and the search terms employed refer to the online Appendix.1
A search of literature identified thirty-six publications about child maltreatment campaigns released between 1995 and 2009. These publications formed the evidence-base for this project (see the online Appendix).2 These thirty-six publications described 21 distinct social marketing campaigns that had been implemented between 1995 and 2009. Those campaigns that were evaluated for impact and/or outcome were identified (see Table 2).
|Child maltreatment social marketing campaigns||12||9||21|
|Campaigns with any evaluation||7||8||15|
|Campaigns with impact and/or outcome evaluation||5||7||12|
Note: * Campaigns directly related to child protection, child abuse and neglect or the determinants of child abuse and neglect (e.g., parenting problems, parental substance misuse, the impacts of domestic violence on children). Published from 1995-2009.