Example 1: The National High Blood Pressure Education Program
The National High Blood Pressure Education Program (NHBPEP) is, I believe, the longest-running behavior-change program to use social marketing concepts, processes, and tools in the United States. It is certainly one of the most successful.
The NHBPEP was established in 1972 by the National Heart, Lung, and Blood Institute (NHLBI) after a series of epidemiological, clinical, and actuarial studies made clear that high blood pressure was a major risk factor for stroke and heart disease. The program's objective was to increase awareness of the linkage between these two conditions and to influence those with high blood pressure to obtain treatment for their problem.
When the NHBPEP began, twenty-three million American citizens were estimated to be hypertensive (National Heart, Lung, and Blood Institute, 1992) according to a relatively strict definition. In subsequent years, the definition of high blood pressure changed to include about sixty million people with blood pressure over 140 /90 or taking hypertensive medication. The program evolved over time as the audience changed. Initially, only 29 percent of the public knew of the link between high blood pressure and stroke and only 24 percent knew that high blood pressure causes heart disease (National Heart, Lung, and Blood Institute, 1973). Only about one-half of all hypertensives were aware of their problem. Thus, the behavioral focus in the early stages of the social marketing project was to get people to get their blood pressure checked. The principal approach to achieving this end was educating people about the link between high blood pressure and disease and getting them to their doctors for a checkup.
Ten years later, 59 percent of the population knew the relationship between high blood pressure and stroke and 71 percent knew it caused heart disease. Ninety-two percent knew that it cannot be cured and that a hypertensive person must always stay on a treatment program (National Heart, Lung, and Blood Institute, 1986). Even further progress was made by 1985, when 91 percent knew of the link to heart disease and 77 percent knew the link to stroke (Roccella, Bowler, Ames, and Horan, 1986).
By 1985, the NHBPEP had brought much of the target market into what I shall later call the Contemplation Stage, that is, aware of the problem and actively thinking about doing something about it. According to a 1985 National Health Interview Survey, about one-half of the population with hypertension had moved beyond the contemplation stage to plan and take action to control their blood pressure. However, almost one-half had not taken action. The project therefore shifted its focus in 1985 to "aware hypertensives" and securing greater levels of compliance (such as taking efforts to control the problem) from this group. This change in strategy was effective in raising compliance to 73 percent by 1988-1991 (National Heart, Lung, and Blood Institute, 1992).
Other behavior changes have also been manifested. Over 95 percent of hypertensives report cutting salt and sodium in their diets, 89% diet to lose weight, and 86 percent exercise (Roccella, Bowler, Ames, and Horan, 1986). However, research has shown that aware hypertensives have trouble staying with their new behaviors and that there remain variations in awareness and compliance across racial and gender groupings. Thus, in recent years, the NHBPEP has emphasized the Maintenance Stage of the behavior -change process and has continued to develop segmented programs for men and women, for blacks and Hispanics, for young, middle-aged, and elderly people, and for people in high-incidence sections of the country. Plans for the decade of the 1990s involve closer targeting of black males over age forty-five (a group where prevalence rates are high and treatment of compliance is low), and of hypertensives in the Stroke Belt (the part of the Southeastern United States where incidence of strokes among hypertensives is ten percent higher than in any other part of the country).
The program began with--and continues to use--a number of important social marketing principles:
- It focuses on behavior. The concern is not with educating and communicating information, but with getting hypertensives to undertake and stay with treatment programs.
- It works through intermediaries. It recognizes that the problem is too large for one organization to tackle and that many other health care institutions have an important stake in reducing the incidence of high blood pressure. NHLBI coordinates high blood pressure programs through forty-one partner organizations.
- It insists on a unified communication approach. Working in cooperation with Porte/Novell, a Washington, D.C. social marketing consultant, NHBPEP regularly develops carefully articulated communications objectives and strategies, defines target audiences, and establishes roles for intermediary groups. All messages are designed to reinforce one another.
- It starts by understanding the customers. The development of strategy begins with target audience members and their perceptions.
- It adapts to changes in the audience. Program strategy follows the target audience as it evolves through various stages of the behavior change process.
- It avoids mass marketing. Careful attention was paid to developing differentiated strategies for different market segments.
- Its message strategies have focused on consequences, both positive and negative, to the hypertensive person. These consequences include those of going through the treatment regimen (the behavior process) and also those of being successful in controlling blood pressure (the behavioral outcomes).
- Its message strategies have also focused on social influence.
- It emphasized the Place component of the mix. By making it easy to check blood pressure in homes and shopping malls, the program tore down barriers to implementing behaviors audiences knew were important.