Getting It Right: A simple approach to changing behavior

Getting It Right: A simple approach to changing behavior Julian B. Young January 2008 Adapted by Parachute for the on-line course Introduction to Child Injury Prevention

Introduction Getting it right means the approach you take to addressing injuries is well thought out, planned, and executed, leading to a positive outcome. Think for a moment about the characteristics of effective strategies for improving health and safety. Some of these characteristics include: Having a clear understanding of the problem to be addressed what is the injury issue? Using evidence and research to inform your work what are the best practices? Adopting a comprehensive approach that combines multiple strategies using the 3E s Considering and/or focusing on root causes, often referred to as the determinants of health what determinants can we influence? Involving the right people the population you are trying to help, communities, governments, leaders, policy-makers, professionals, experts (those that know the most about the issue you are trying to address may not necessarily be those you first think of) have those most affected involved in solving the issue. Working collaboratively in partnership with others who can affect change who are our partners? Allocating resources appropriately and being cost effective what do we need and where can we get it? These characteristics are simply just good health promotion principles. If we incorporate these principles into our work to address injuries, we will have a much greater chance of getting it right. Overview of Social Marketing 1 One model we can use to help us get it right is called Social Marketing. Improving the wellbeing of individuals, groups, or the overall population is the objective of social marketing. This is achieved by influencing behaviour through a sound understanding of what drives the target audience s behaviour, and what will motivate them to change. All of this is done by drawing on the same principles and techniques of marketing to address health and social problems. The difference though, is that the welfare of the consumer is positively changed, not that of the marketer. More important than knowing what social marketing is, is perhaps understanding what social marketing isn t. Social marketing is not just education and awareness. It is not simply communication, or advertising. It is more. Advertisers successfully influence consumer behaviour by investing heavily in understanding their customer s wants, desires, and aspirations. In so doing, they are able to position their product in a way that is appealing to their audience they want the audience to feel good about buying their product. It is the emphasis on the consumer the person whose behaviour we trying to influence, that sets social marketing apart from traditional approaches to behaviour change. Consider the two stories below. One follows a traditional approach to injury prevention, while the other adopts a more consumer-oriented, comprehensive strategy. 1 Much of the information contained in this document has been adapted from: Turning Point National Program Office - University of Washington. (n.d). The basics of social marketing: How to use marketing to change behavior. Washington, D.C.: Turning Point. Page 1

Traditional Approach A CAPC/CPNP site wants to prevent children from falling in their homes. They believe that the caregivers 2 that attend their Centre don't have all the information they need to understand the risks of injury to young children at home from falls and what they can do to make their homes safer. They develop a pamphlet that discusses the fall risks and include a home safety checklist to distribute to parents in the program. All the parents attending the Centre during the year receive the pamphlets and the campaign is deemed a success. But, one year later, Centre staff are still hearing stories about children falling at home. Putting the Consumer First A CAPC/CPNP Centre wants to prevent childhood falls in the homes of the families they serve. They decide that they must first talk with their caregivers to find out what they know already and what they think about falls at home. Caregivers told them that they thought that falls were just a natural part of a child s experience and that they couldn t be prevented. Some thought that they could teach their 10 month old not to go near stairs and that he would always obey that rule. Others knew that having safety gates was a good idea but they didn t have the money to pay for a permanently mounted gate and didn t know haw to install it, even if they could afford it. Upon further discussion, caregivers admitted that they wanted to do everything they could to keep their children safe but they found it difficult, particularly those that had several children. They couldn t have eyes everywhere. The staff determined, based on the direct input of caregivers, what they think would help them make their homes safer, determine what the barriers to behaviour change might be, and what benefits the caregivers feel they would attain if they made their homes safer. Armed with this information, they develop a program called Peace of Mind. In each session of their parenting course, caregivers choose two falls topics to discuss one pre walking age and one for the toddler age. They then share their ideas on how to prevent the fall. Staff show simple graphics that describe the fall and how to prevent it. This program design was based on what the group had learned about caregivers' knowledge and attitudes about falls. Since safety gates are known to help prevent falls on stairs and buying gates are often a barrier for many parents in the program, caregivers can pick up a coupon for a safety gate through the local hardware store. The CAPC/CPNP program provides a list of carpenters/volunteers who will install the gates free of charge. The cost of these modifications is supported by a local community organization. The carpenters report on how many gates they have permanently mounted. Home visitors and public health nurses also note when gates are in use. The caregivers were asked how they felt about the program. They liked it so much that they have asked for other topics to be addressed and have asked for help obtaining other safety devices such as smoke alarms. The program is deemed a huge success and ongoing funding is being sought. Consider the differences between these two stories. In the first instance, the group assumed they knew what caregivers needed to know and what they thought about the problem. In the second case, the group took the time to understand the issue from the caregivers perspective. They asked caregivers what they thought and spent time understanding their perceptions, beliefs, and concerns about the problem. The reason the group was so successful in the second story was because they applied good health promotion principles they followed a social marketing approach. 2 We are using the term caregiver to include parents, grandparents, foster parents, and anyone else who is responsible for the care of a child. Page 2

A Word About Language Before we go any further, lets take a moment to talk about language. Many people get hung up on the terminology Social Marketing. They feel they don t have the expertise to apply this approach, that it is too costly and too complex. In reality, social marketing is just a way of thinking and approaching a problem. If we incorporate all the key elements of good social marketing as we develop an injury prevention strategy, we are simply applying solid health promotion theories and practices. Don t get overwhelmed by the language and terminology. Just remember, you can do it! You are going to get it right! This resource has been developed to provide injury prevention practitioners with a guide to get it right. Some of the key concepts of social marketing are described in this document and we have developed a tool to guide your thinking as you develop your programs and take action on injury. Key Concepts for Getting it Right Barriers Barriers are the things identified by the target population that make it difficult for them to change behaviour. Barriers involve both external and internal factors. External factors include things like lack of income supports for caregivers to make their home safer for children, lack of transportation to attend a parenting program, or inability to afford a healthy diet for their family. Internal factors include perceptions and beliefs. For example, the belief that young children can be taught not to go near stairs, or that accidents cannot be prevented. Understanding what the target audience sees as the barriers to behaviour change will help you formulate a strategy that takes these barriers into account. Essentially, you design your program in a manner that removes these barriers or at the very least helps you side-step them. In the story described above, the community group recognized that caregivers might not have the financial means or ability to make home modifications - both barriers to behaviour change. As a result, their program included components to address this. The group also discovered that caregivers were worried about their child s safety but didn t think they could do much to prevent falls. The program name came directly from comments of parents. Benefits Benefits are what the target audience identifies as the advantages of adopting a new behaviour. Benefits can be described as the positive results, feelings and attributes the audience associates with the new behaviour. Benefits addresses what s in it for them. For example, installing gates at the top and bottom of stairs removed a worry, and having a gate that could be used to keep a child in a room (i.e. the kitchen when the mother was making supper), let the mother supervise her child more consistently. Page 3

Competition Competition is one of the features of social marketing that sets it apart from other health promotion practices. Competition refers to the behaviours and related benefits the audience receives from their current behaviour that they prefer to those of the new behaviour. Overcoming the benefits the audience believes it gets from the negative behaviour is critical to helping them adopt the new behaviour. In our example. some caregivers actually did have spring-loaded safety gates but rarely used them. They also were may be hesitant to install gates because then you have to open them/remove them every time you want to go up and downstairs, or leave a room. This is inconvenient. Also, they are hard to open. Competition may also include those who are promoting an alternative to the desired behavior. There is not an obvious illustration in this example but there could be one at a school or day care. Custodians may have their performance rated on how shiny they keep the hallways and floors. Shiny (waxed) floors could cause children to slip and fall. Determinants of Behaviour This concept gets at what the target audience thinks about the behaviour. It looks at how ready they are to change and guides the types of interventions that will be required. For example, is the caregiver even aware that their child is at risk of falling? Have they decided they need to make home modifications to address their risk, but lack the funds to do so? Each of these scenarios requires a different approach. In the first instance, we d need to influence the caregiver s understanding of the problem. In the second, we need an intervention that helps support the caregiver to make the modifications. For more information on the Determinants of Behaviour, refer to the Stages of Change Model in Lesson 4 of the Introduction to Child Injury Prevention. Exchange Theory Exchange theory is grounded in the understanding that people will either adopt/ reject or maintain a behaviour in exchange for benefits that they think outweigh the costs of the behaviour. These costs are not necessarily always in the form of dollars. They may also be the perceived cost to changing lifestyle (i.e. something will take longer), Returning to the example installing the safety gates the cost having to constantly remove it, or open and shut it outweighed the benefit of reducing the risk of a fall for some caregivers. By addressing this cost leaving the gate open when the child was asleep, the caregiver was able to accept the behavior change. (Note: once the family learned how to open and close the gate, they decided to keep it closed all the time.) Market Research Don t think that this has to be overly complicated. Market research is simply about getting to know your target audience. By asking the right questions, you develop an understanding of their beliefs, attitudes, perceptions, and values. Further, you can assess their readiness to change (see Determinants of Behaviour), and what they see as the barriers and benefits. The results of this dialogue will allow you to develop programs that lead to behaviour change. Page 4

Market Segmentation Market segmentation recognizes that no single strategy is going to address the needs of the whole population. By segmenting the target audience based on common attributes such as their readiness to change, the ages of their children, their income or access to safety resources, social factors, the extent of their risk, etc, you take into account differences among the population and can tailor your strategy to address the uniqueness of your audience. Market segmentation is a fabulous tool for addressing cultural diversity too. Target Audience This refers to the primary audience or priority population you have selected for your program, based on market segmentation. It is the behaviour of your target audience that you work to influence through your strategy. Also important is to recognize that in order to influence the behaviour of your target population, you sometimes need to first influence the behaviour of others. In rental situations, landlords may need to approve the installation of permanently mounted gates before caregivers can install the gates. The so-called five Ps of social marketing take all of the above concepts and help us incorporate them into a comprehensive strategy. By ensuring we have the right mix of interventions, properly addressing each of the Ps, we significantly increase or chances of getting it right. The five P s are described below 3. Product Product refers to the desired behaviour change and the associated benefits we are asking the target audience to consider. For example, we want caregivers to install and use safety gates to minimize the risk of their child having a serious fall. Product may also refer to the program or service you develop to support the adoption of the desired behaviour. For example, a comprehensive home visiting program, that supports caregivers in a variety of ways, including addressing their safety needs, would also be considered a product. Price Considering price helps us to identify the barriers, costs, and benefits associated with the behaviour. By taking price into account, we can design programs that reduce the cost of the desired behaviour, and increase the cost of the competing risky behaviour. Applying this concept to the falls prevention example, addressing price guides us in identifying and seeking ways to overcome the financial and physical, barriers that caregivers face in making their homes safer. 3 These 5 P s are integrated into the 5A s of Behaviour Change in Lesson 6 of the Introduction to Child Injury Prevention.. Page 5

Place Place is all about making it easy for your audience to receive your message or service. If you don t make delivery accessible, you won t reach your target audience. Place refers to understanding where and when your target audience will be when they perform the desired behaviour, understanding where they will most easily access your program or service, and reaching them where they are most likely to be thinking about the behaviour. A good placement strategy will offer services or products in a location that is easy for your target audience to access and in a manner that is convenient and enjoyable for them. This approach will lead you to offer services and products where the audience is already thinking about your issue. The Family Resource Centre, or the clinic where children go for their shots would be places where a falls prevention program could be offered. Having the safety gates directly available at locations caregivers attend, or at a nearby store, places the product where caregivers can access it. Promotion To be successful, people have to know about your program or service. Sometimes this means promoting the program directly to your target audience (caregivers) or to those who can influence the target audience to check out your service (i.e. their doctor, public health nurse, best start worker). Promotion refers to the specific communications message, materials, channels, and activity that will effectively reach the intended audience. Promotion leads you to consider where and when the target audience will attend to your message (radio, newspaper, pamphlets, discussions at parenting groups, drop-in playgroups, etc.) and the type of message they are most likely to respond to (i.e. a fear message, humour, emotional plea, etc.). Promotion also helps identify who they are most likely going to listen to. Besides advertising the program at the Centre, it could also be promoted by other practitioners that work with caregivers in the health, social service or educational areas. Sometimes other caregivers or the caregivers parents may also be perceived as credible sources of information. Policy This final P is a consideration within each of the other four Ps. Policy recognizes the need to consider stimulating changes in policy and rules as a component of influencing behaviour. For example, removing a policy that requires the cleaner to achieve a shiny floor to get a good performance rating is an example of addressing policy at an organizational level. Advocating for more dollars for a safety gate program and requiring landlords to permit the installation of gates is an example of addressing a public policy issue. Along each step of your thought process, you need to consider the impact of policy and whether a policy or policies must be changed or new ones created, in order to support a shift in behaviour. See Lesson 7, Influencing Public Policy, in the Introduction to Child Injury Prevention course. We hope that this document has helped shape your ideas and provided a new way of thinking about injury prevention. While we have used the language of Social Marketing to illustrate the things you need to consider and incorporate within your falls prevention strategies, all we have done is simply described some good principles of health promotion. If you follow these principles you will get it right. The following tool is intended to guide your thinking and processes as you develop specific injury prevention strategies Page 6

Social Marketing Planning Tool 1 The purpose of this planning tool is to get you thinking about the various aspects of your strategy, so that you can begin to pull together the key ingredients to getting it right. The Social Marketing Planning Tool is useful in guiding your thinking and creating the right mindset for addressing behaviour change. It is not intended to encompass all social marketing concepts. Part 1 Framing the Issue Questions to Consider Record Your Answers What is the problem or issue we want to address? What is the behaviour we are trying to change? What is the new behaviour we want to achieve? Who is affected by the problem and to what degree? What could happen if we don t address the problem? 1 Adapted from: Lagarde, Francois, Social Marketing Quarterly, Vol X, No. 1, Spring 2004 and from CDCynergy: My Plan Tool Page 7

Part 2 Target Audiences and Actions List of Target Audiences What do you want them to do (behaviour, action, decision, etc)? Page 8

Part 3 Audience Analysis Complete this table for each target audience. Questions to Consider Record Your Answers What do we know about those who have adopted the behaviour already? (Demographics: age, gender, rural/urban, social status, level of education, occupation, family status, etc) What do we know about those who have not? (Demographics: age, gender, rural/urban, social status, level of education, occupation, family status, etc) How will our target audience benefit by adopting the new behaviour? What are the barriers (real or perceived) to adopting the new behaviour? How ready is our audience to change? Base this on where our target audience is in terms of the stages of change model. Page 9

Who is the target audience most likely to listen to? Who do they find credible? Who will influence their decisions? What types of media can we use to reach the target audience? Where do they get their information? (Newsletters, posters, workshops, training sessions, emails, mass media, etc) Where does the audience already gather? Where should we go to reach them? Page 10

Appendix A Applying the Stages of Change M odel to Children s Falls Prevention Example 1: Changing the caregiver s behavior Stages and Process of Change Application: changing the behaviour of caregivers to prevent falls Stage 1 Pre-contemplation: consciousness-raising This describes individuals who are not even considering changing behavior, or are consciously intending not to change. Stage 2 Contemplation: recognition of the benefits of change The stage at which a person considers making change to a specific behavior. Stage 3 Determination or Preparation: identification of barriers The stage at which a person makes a serious commitment to change. Stage 4 Action: program of change The stage at which a behavior change is initiated. Stage 5 Maintenance: follow-up and continuing support Sustaining the change and achievement of predictable health gains. - Caregivers unaware that falls are a serious injury issue for children. - No intention of making in-home adjustments or other changes in behaviour. - Caregivers aware that falls cause serious injury to children - Caregivers begin considering how they can make their homes safer, and how they can modify their behaviour - Beginning the process that in-home adjustments need to take place. - Looking for options regarding money for safety gates and agencies/ service providers in the area that would help install them (if needed). - Contracting an individual/agency to access a safety gate and come into the home to install gate (if needed). - Consistently using the safety gates. - checks to make sure spring-loaded gates are tight and permanently mounted gates are still securely fastened to the wall. -Stays informed regarding other ways to prevent in-home falls. Page 11