Case Analysis

LIVERPOOL’S CHALLENGE: USING SOCIAL

MARKETING TO ADDRESS OBESITY

NAME: MAXWELL MANU

INDEX NUMBER: 10202910
CONTENTS
INTRODUCTION .......................................................................................................................... 2
CASE SYNOPSIS .......................................................................................................................... 2
ADRESSING QUSTION ONE ...................................................................................................... 4
Self-efficacy Theory ....................................................................................................................... 4
Social Learning and Social Cognitive Theory ................................................................................ 4
Theory of Reasoned Action ............................................................................................................ 5
Theory of Planned Behavior ........................................................................................................... 5
Trans-Theoretical or Stages of Change Model ............................................................................... 6
Health Action Process Approach .................................................................................................... 6
CONSIDERING A BEHAVIORAL CHANGE CHALLENGE .................................................... 7
ADRESSING QUSTION TWO ..................................................................................................... 9
ADRESSING QUSTION THREE ................................................................................................ 14
Strengths of Campaign approach in creating awareness............................................................... 14
Limitations of Campaign approach in creating awareness ........................................................... 15
REFERENCE ................................................................................................................................ 16

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INTRODUCTION

Around half of all illness is linked to choices people make in their everyday lives. Whether that is

the choice to smoke, drink excessively, eat too much or exercise too little. These patterns of

behavior may be ‘deeply embedded in people’s social and material circumstances, and their

cultural context (National Institute for Health and Clinical Excellence [NICE], 2007). The health

and economic impacts of major health problems that are, in part, avoidable are well known and

there is overwhelming evidence that changing people’s health related behavior can have a major

impact on some of the largest causes of mortality and morbidity and their costs to society (House

of Lords Science and Technology Committee, 2011). For instance, obesity is an eminently

avoidable but nonetheless growing problem in Europe. Addressing obesity is a key goal of much

public health policy. The condition has been linked with an increased risk of a wide range of

conditions, including cardiovascular disease and diabetes.

CASE SYNOPSIS

The case examines the development and impact of a social marketing program name the

“Liverpool’s Challenge” which was aimed at reducing obesity in Liverpool, a large city in the

north-west of England that has a higher than average social disadvantage and worse than average

health profile. Recognizing that government campaigns promoting healthy eating and exercise

tended to have limited success, Liverpool Primary Care Trust (PCT), the local health

commissioning body social marketing team focused on developing insights into the factors that

motivate people to change their habits. They found that, while most people were aware of benefits

of a healthier diet and were keen to lose weight, they found it difficult to stick to a long-term

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regime and often felt isolated and therefore unmotivated. The subsequent social marketing

program that was developed formed relationships with the target audience using Customer

Relationship Management (CRM) techniques more commonly used in the commercial sector, to

provide people with ongoing support and feedback within the framework of a city-wide challenge

to residents to pledge to lose weight.

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ADRESSING QUSTION ONE

Several behavioral change theories have been recorded in literature. These theories explain how

individuals adopt several behavioral traits through established theoretical procedures. The

following are accounts of some behavioral change theories that will be considered for this analysis:

Self-efficacy Theory

Self-efficacy is an individual's impression of their own ability to perform a demanding or

challenging task such as facing an exam or undergoing surgery. This impression is based upon

factors like the individual's prior success in the task or in related tasks, the individual's

physiological state, and outside sources of persuasion. Self-efficacy is thought to be predictive of

the amount of effort an individual will expend in initiating and maintaining a behavioral change,

so although self-efficacy is not a behavioral change theory per se, it is an important element of

many of the theories, including the health belief model, the theory of planned behavior and the

health action process approach.

Social Learning and Social Cognitive Theory

According to the social learning theory (more recently expanded as social cognitive theory,

behavioral change is determined by environmental, personal, and behavioral elements. Each factor

affects each of the others. For example, in congruence with the principles of self-efficacy, an

individual's thoughts affect their behavior and an individual's characteristics elicit certain

responses from the social environment. Likewise, an individual's environment affects the

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development of personal characteristics as well as the person's behavior, and an individual's

behavior may change their environment as well as the way the individual thinks or feels. Social

learning theory focuses on the reciprocal interactions between these factors, which are

hypothesized to determine behavioral change.

Theory of Reasoned Action

The theory of reasoned action assumes that individuals consider a behavior’s consequences before

performing the particular behavior. As a result, intention is an important factor in determining

behavior and behavioral change. According to Icek Ajzen, intentions develop from an individual's

perception of a behavior as positive or negative together with the individual's impression of the

way their society perceives the same behavior. Thus, personal attitude and social pressure shape

intention, which is essential to performance of a behavior and consequently behavioral change.

Theory of Planned Behavior

In 1985, Ajzen expanded upon the theory of reasoned action, formulating the theory of planned

behavior, which also emphasizes the role of intention in behavior performance but is intended to

cover cases in which a person is not in control of all factors affecting the actual performance of a

behavior. As a result, the new theory states that the incidence of actual behavior performance is

proportional to the amount of control an individual possesses over the behavior and the strength

of the individual's intention in performing the behavior. In his article, Further hypothesizes that

self-efficacy is important in determining the strength of the individual's intention to perform a

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behavior. In 2010, Fishbein and Ajzen introduced the reasoned action approach, the successor of

the theory of planned behavior.

Trans-Theoretical or Stages of Change Model

According to the trans-theoretical model of behavior change, also known as the stages of change

model, states that there are five stages towards behavior change. The five stages, between which

individuals may transition before achieving complete change, are pre-contemplation,

contemplation, preparation for action, action, and maintenance. At the pre-contemplation stage, an

individual may or may not be aware of a problem but has no thought of changing their behavior.

From pre-contemplation to contemplation, the individual begins thinking about changing a certain

behavior. During preparation, the individual begins his plans for change, and during the action

stage the individual begins to exhibit new behavior consistently. An individual finally enters the

maintenance stage once they exhibit the new behavior consistently for over six months. A problem

faced with the stages of change model is that it is very easy for a person to enter the maintenance

stage and then fall back into earlier stages. Factors that contribute to this decline include external

factors such as weather or seasonal changes, and/or personal issues a person is dealing with.

Health Action Process Approach

The health action process approach (HAPA) is designed as a sequence of two continuous self-

regulatory processes, a goal-setting phase (motivation) and a goal-pursuit phase (volition). The

second phase is subdivided into a pre-action phase and an action phase. Motivational self-efficacy,

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outcome-expectancies and risk perceptions are assumed to be predictors of intentions. This is the

motivational phase of the model. The predictive effect of motivational self-efficacy on behavior is

assumed to be mediated by recovery self-efficacy, and the effects of intentions are assumed to be

mediated by planning. The latter processes refer to the volitional phase of the model. Which is

based on the resultant actions of the individual.

CONSIDERING A BEHAVIORAL CHANGE CHALLENGE

A common behavior that is frowned upon in the Ghanaian setting is smoking. Various culprits of

this practice share that ordeals and challenges they face in dealing with the attempts to quit and

this phenomenon can clearly be scrutinized under the lenses of behavioral change theories.

Two theories that can help in understanding challenges associated with behavioral change are the

theory of planned behavior and the Trans-Theoretical model.

The theory of planed behavior is grounded on the assumption that the strength of an individual’s

intentions on changing a particular behavior could go a long way in aiding in the behavioral

change. Considering the fact that almost all smokers are addicted the act, there may be the disparity

between the willingness to change behavior and the actual intentions backing that behavioral

change. According to the propounded theory, the strength of the intentions of the individual may

go along to help in the behavior change which is a challenge to most smokers who are somewhat

addicted to the act and may have a very intention on changing from that behavior.

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The trans-theoretical model can also be a yardstick to understanding challenges in behavioral

changes. This model is built on the assumption that behavioral changes occur in series of stages.

The challenge of this theory to behavioral change is that, for a particular behavior such as smoking,

which may follow this model. For instance what if an individual reverts from one stage to another,

how then, can progress be measured. The theory states that, during preparation, the individual

begins his plans for change, and during the action stage the individual begins to exhibit new

behavior consistently. This is a challenge in addictions such as smoking where progress may not

necessarily be observed in consistent nonsmoking but back and forth approach.

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ADRESSING QUSTION TWO

Behavior change approaches promote health related activities through individual changes in

lifestyle that are appropriate to people’s settings. The assumption is that, before people can change

their lifestyle, they must first understand basic facts about a particular health issue, adopt key

attitudes, learn a set of skills and be given access to appropriate services. The simple logic is that

some behavior leads to ill-health, and so persuading people directly to change their behavior must

be the most efficient and effective way to reduce illness. This reasoning is attractive to decision-

makers because it promises quantifiable results within a short time frame, can deal with high

prevalence health problems, is relatively simple and offers savings in health care services,

especially for people suffering from chronic diseases.

These approaches attempt to provide new knowledge and skills that people need to adopt a

healthier lifestyle. They use a range of techniques including interactive communication

technologies, motivation, counselling, persuasion, influencing social norms and coercion. Health

promotion has also relied on pre-packaged, top-down programs especially for health education and

multi-risk factor reduction interventions. These have not guaranteed a change in behavior and has

led to a “blaming of the victim”, for example, for drinking too much alcohol or continuing to

smoke even though people know the behavior is harmful. This can create feelings of mistrust

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between “expert” practitioners and the public, further exasperated by changes in health messaging,

for example, on the safe levels of alcohol consumption.

Another important factor to consider in behavioral change methods is the power of social group

action in changing behavior as described by the Liverpool Challenge case study. In Ghana for

instance, a case we could liken this to, is the END TRAMADOL NOW campaign embarked by

certain individuals in the Ghanaian media landscape entreating individuals, in collectives,

neighborhoods, districts and certain suburbs of the capita town, Accra where there are suspicions

of the abuse of the tramadol drug, to come together and help people in these areas stop the abuse

of the drug.

There are certain social norms such as peer pressure, youth unemployment, and negligence, lack

of proper education on medications and a host of other which has contributed to a lot of the youth

clinging on such drugs and abusing them. Over the past few months (2018) in Ghana, there has

been efforts to educate the youth on the effects of these drugs and hence the group counseling and

other social group initiatives undertaken to revert these behaviors. The resultant responses are

telecasted on national for everyone to join in the fight against drug abuse. This is an approach that

enforces the social group power approach as adopted by the Liverpool Challenge case and serves

as a success factor in similar interventions like drug abuse in Ghana.

Fundamentally, people do not resist change, but they do resist being changed. This is a situation

made worse by health promotion programs that have an over-reliance on didactic styles of

communication, inadequate audience segmentation, and inappropriate message content and weak

material development.

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The art of health promotion is knowing when and how to use the science to produce a desired

outcome but many practitioners lack the competence and confidence to achieve this in different

contexts. Behavior change and health promotion can be made more effective and sustainable if the

following elements are included (1) a strong policy framework that creates a supportive

environment and (2) an enablement of people to empower themselves to make healthy lifestyle

decisions.

It is important to recognize that a strategy to influence health behaviors may involve a number of

different actions, less attention has been placed on making use of psychological tools that can

influence internal and social factors that impact on behavior (Prendergast et al., 2008).

The most passive and least intensive of options is the simple distribution of information, perhaps

through the mass media or through more targeted means, such as in primary care physician

practices. Improving health literacy through health education is a more intensive approach that can

help communicate issues such as how to interpret risk. This could be combined with provision of

information on the health consequences of some actions, which can include visual prompts at the

time that decisions are being made. This may, for instance, include voluntary industry agreements

or legislative requirements on the provision of information on the calorie, fat, sugar and salt content

of foods in restaurants.

Another approach is to make use of one-to-one or group-based learning and support. This may

often be delivered by health-care professionals, as well as by peer groups. People often like to have

an external pressure or commitment, challenging but sympathetic, to help them to do the things

they want to do anyway. For other individuals, however, being part of a mutually reinforcing group

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may be the key to behavior change, the peer-to-peer elements of Weight Watchers and Alcoholics

Anonymous are clearly key components of those approaches. Mechanisms can also be used to help

routinize health promoting behaviors, such as the use of pedometers for walking, or food diaries

to monitor food consumption.

Many actions can help improve access to healthier choices, without preventing individuals

engaging in unhealthy activities. This approach can again draw on what is known from psychology

that individuals will generally make do with the portion size on their plates; therefore, reducing

the size of the portion (or indeed the plate) may help to reduce calorie intake. Other measures

might involve reducing the size of chocolate bars, which does not limit the ability of a person to

buy further bars if they so wish. In the same way, ‘all that you can eat’ buffet-style restaurants and

happy hour bars are likely to encourage an individual to consume more calories than they would

normally. Legislative/ regulatory change may be required to reduce access to these types of

products, particularly if they have commercial benefits to business.

Measures to change the physical environment in which people live can also be used to influence

their behavior; examples are the provision of dedicated green spaces or cycle lanes to encourage

cycling; installation of traffic-calming measures in residential areas to change driver behavior; and

building regulations intended to reduce noise pollution between properties.

Measures might also be taken to address automatic behavior responses

(Marteau, Hollands & Fletcher, 2012); for instance, the way in which products are displayed at the

point of sale could be varied for example, not having cigarettes on view at checkout counters, or

having healthy foods near these checkouts. In the same way, access to salads in self-service

restaurants could be made easier, while less healthy foods might require a bit more effort to reach.

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Financial measures have long been used as part of public health policies. Many have assumed that,

in line with conventional economic theory, increasing/ decreasing costs associated with

unhealthy/healthy activities will have an impact on demand and consumption patterns. Behavioral

economic aspects have not been explicitly considered in their design. Traditionally, these measures

have taken the form of specific taxes on the consumption of some goods such as cigarettes or

alcohol. To a lesser extent, taxation has also been used to tax unhealthy foods such as fats or sugary

drinks, although several European governments have introduced ‘fat taxes’, but not always

successfully (as was the case in Denmark (Snowdon, 2013)). Subsidies for healthy products can

also be used. These may be targeted at either the consumer or perhaps the supplier (this may also

counter any incentives that the food industry receives to display certain products in prominent

locations). In addition to taxation, other financial incentives may be targeted at specific

individuals, for instance through the provision of vouchers to reduce the costs of gym membership,

or regulations around the pricing of products. These again assume that individuals operate as

rational individuals in responding to price signals. Actions informed by behavioral economics can

also make use of material or financial incentives to reinforce behavior change, and examples can

be seen in respect of smoking-cessation or weight-loss program. In psychology, approaches that

get individuals to make a formal commitment to behavior change have been shown to have impact.

Such commitment contracts are sometimes combined with financial incentives. Funds may be

earned or losses averted, depending on progress in achieving health-promotion goals. Such

measures can also be used to increase participation rates in health-promoting activities, such as

going to the gym.

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ADRESSING QUSTION THREE

The pecks of social campaign on behavioral changes may range from observations of enormous

strengths as against several other limitations. The challenge for behaviorists and entities

responsible or interested in some sought of behavioral change is to identify such strengths and

conflicting limitations to create the best strategies for social campaigns. The subsequent

paragraphs enlists several strengths and limitations of social campaigns;

Strengths of Campaign approach in creating awareness

 Encourages individuals to adopt healthy behaviors which improve health.

 Views health as property belonging to individuals.

 People can make real improvements to their health by choosing to change their lifestyle.

 It is people’s responsibility to take action and look after themselves.

 Involves a change in attitude followed by a change in behavior.

 "Pester power" means that it cannot be easily ignored.

 Can be aimed directly at specific audiences, e.g. dangers of anorexia in teenage girl’s

magazines.

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  Provides information for people to make well-informed choices independently

(empowerment).

 If enough people are educated, the knowledge becomes common sense.

Limitations of Campaign approach in creating awareness

 Depends on a person’s readiness to take action.

 Complex relationship between individual behavior and social and environmental factors.

 Behavior may be a response to a person's living conditions which may be beyond individual

control, e.g. poverty or unemployment.

 People may feel preached at or dictated to and so resist campaigns and promotions.

 People may throw away promotion materials like leaflets without reading them.

 Considering televised campaigns, many people don't watch television advertisements that

are associated with health promotions.

 Email and website promotions are limited to those with internet access.

 Considering internet based campaigns, health websites are rarely used.

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