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Instruments of Developing Social Marketing in Public Health

Abstract This paper examines the way in which social marketing can be developed in public health and provides a set of practical instruments in this regard. Social marketing is an important tool in generating behavioural change and its usefulness in public health was proved by previous studies. However, it is still overlooked by many public health specialists, mainly because they lack basic instruments in this regard, especially knowledge and technical support. This study provides an opportunity to advance the implementation of social marketing and it priorly addresses to: national authorities in developing public health policies and strategies, medical curriculum developers, teachers, project managers and team members of health promotion programs. The research is interdisciplinary, applicative, descriptive, with a qualitative approach, based on logical-deductive reasoning. The novelty of the paper is expressed by the proposed total framework of implementing social marketing in public health, that comprises three dimensions: political, training and collaborative. The political dimension implies a unified application of the concept at the national level through specific strategies and encouraging program developers to use marketing techniques in influencing health behaviour. The training dimension implies courses provided at different levels and stages of training: students, master students, specialists. The collaborative dimension requires the creation of joint teams and clear distribution of roles for each member, of which at least one should be a specialist in social marketing. According to these three dimensions, the study describes three instruments (a guide, a curriculum and a sketch of the team) that were created for developing social marketing in public health in countries like the Republic of Moldova, where the concept is still not widely known and accepted. This study tends to give support for researchers in promoting social marketing techniques.


Introduction
This paper has as an objective to examine the way in which social marketing can be developed in public health by describing a total framework and to provide a set of practical instruments in this regard (a study program, a guide, a team sketch). This emphasises the novelty of the paper -a complex of tools in implementing social marketing integrated in a total framework. Social marketing is an important tool in generating behavioural change and its usefulness in public health was proved by previous studies. However, it is still overlooked by many public health specialists, mainly because they lack basic instruments in this regard, especially knowledge and technical support. This study provides an opportunity to advance the implementation of social marketing and it priorly addresses to: national authorities in developing public health policies and strategies, medical curriculum developers, teachers, project managers and team members of health promotion programs. The research is interdisciplinary, applicative, descriptive, with a qualitative approach, based on logicaldeductive reasoning.
Practitioners in social marketing field can use international guides like: Communication for Behavioural Impact used by the World Health Organisation, CDCynergy Lite: Social marketing made simple applied by the Centers for Disease Control and Prevention (USA), the social marketing guide of the European Center for Disease Prevention and Control. The disadvantage is that a good knowledge of English is required and the instruments are not adapted to the national/local environment.
Regarding the curriculum development in the field of social marketing there are little theoretical support, but there is no lack of practical implementation at the international level. Although, the learning objectives tend to be similar, there is no detailed description of the methods of teaching learning used, that can make the courses being more efficient.
Even if the instruments described in this article were created for the Republic of Moldova, they are relevant for the researchers in other countries too. Firstly, these instruments integrated in the total framework are able to enhance the practical field that can help in promoting and implementing the social marketing concept, in any country. Secondly, the adjustments that may be necessary are usually of a minor importance: some national examples relevant for a certain country added in the guide, the naming and order of the sections of the curriculum. Finally, this paper will contribute to the advancement and development of social marketing in public health.

Theoretical background
Alan Andearsen (2002) presents four major problem areas regarding implementing social marketing, identified through a series of more than 300 personal interviews, 100 field questionnaires, and two focus groups developed by the Institute of Social Marketing: (1) There is a lack of appreciation of social marketing at top management levels. (2) The field has poor "brand positioning", it lacks clarity and is perceived by key influential people as having several undesirable traits. (3) There is inadequate documentation and publicity of successes. (4) Social marketing lacks academic stature. As a solution he proposes to "marketing social marketing"; and also emphasises a need for committed and extensive private sector involvement; creation of academic programs and further legitimisation of social marketing as a scholarly field of study.
To complement this solution it is important to provide several instruments, especially a guide, a curriculum and a sketch of the social marketing team in order to increase the appreciation of the discipline, the clarity of the concept, to promote the successful social marketing campaigns and to offer an academic stature to social marketing. In order to create new tools it is important to analyse the existing ones, which already have proved their effectiveness. The current study presents a short description of three guides of implementing social marketing in public health, and some social marketing curriculum applied in different countries. integrated strategy; (5) Preparation of implementation plans and budget; (6) Implementation and monitoring of the strategy; (7) Evaluation after the epidemic outbreak has ended.
CDCynergy Lite: Social marketing made simple (US Department of Health and Human Services. Centers for Disease Control and Prevention) is a guide to create effective social marketing plans, launched by the US Center for Disease Prevention and Control (CDC). The planning process is structured in 6 stages: problem description, market research, marketing strategy, interventions, evaluation, implementation. The stage of describing the problem involves: formulating the health problem, identifying its causes, identifying potential audiences, conducting a SWOT analysis (strengths, weaknesses, opportunities and threats). Market research includes: defining research questions, developing a research plan, conducting and analysing market research, summarising the results. The market strategy involves selecting the target segment or segments, defining the current and desired behaviours for each segment, prioritising the audience / behaviour pairs, describing the benefits offered, writing the goals of behavioural change, selecting the interventions to be performed, writing the purpose for each intervention. In the interventions chapter, the members will be selected and assigned the roles for the planning team, writing the specific and measurable objectives for each activity, developing a plan with a program and budget included for each intervention. The evaluation, as a stage, includes: identifying the elements of the program to be monitored, selecting the key evaluation questions, determining how the information will be gathered, conducting a data analysis and reporting plan, drawing up a graph and drawing up the budget. At the stage of implementation, preparations for the launch must be made. The CDCynergy Lite Guide also contains attachments with forms that help you plan the programs for each stage.
The European Centre for Disease Prevention and Control (ECDC, 2014) proposes a social marketing guide for managers and practitioners of public health programs, developed by Jeff French and Franklin Apfel (and with the contribution of other authors). It outlines the basic principles of social marketing and the actions that can be implemented as part of communicable disease prevention initiatives or other public health programs. The guide is structured in three parts: the first part presents a theoretical foray into the basic concepts of social marketing, the second part provides a logical framework for applying social marketing in the development and implementation of public health interventions, and the third part contains a set of supporting forms for the implementation of the activities described in the previous parts. The accessibility of the language, the balanced content (the theoretical material is briefly reproduced, being enriched with figures) and the practical examples make the guide easy to use and effective even for those who do not have social marketing knowledge.
Here the basic concepts of marketing are rendered through the perspective of the Consumer/Citizen Triangle which includes the following elements: insight, exchange, competition, audience segmentation, behaviour, method mix, and the citizen/consumer/patient placed in the centre. The guide uses a logical framework of action on social marketing that includes four stages: scope, testing, adoption, learning and action.
As we can see, some guides are specialised on a certain domain, communicable or noncommunicable diseases, outbreaks. Of course there exist some differences, but the essence of social marketing remains the same and can be adapted to a specific situation.
Regarding the curriculum development, in the specialised literature there are multiple studies about the general marketing curriculum, that analyse the current status and trends (McDaniel and Hise, 1984); the marketing role as a discipline and its orientation toward developing practical competencies or academic skills for future scholars (Clarke, Gray and Mearman, 2006); the pro and cons of specialising into various marketing sub-disciplines (Conover and Byron, 1988). But the training programs in the field of social marketing are approached only tangentially. However, there are examples of curricula implemented by various institutions, especially in the United States of America. This fact highlights the importance of creating the theoretical foundation of the aspects related to the curriculum in social marketing (especially specialised in public health), in order to expand its implementation. Further are presented the learning objectives and teaching methods of some syllabuses of the social marketing discipline.
The syllabus for the Social marketing course held at Vesalius College, Brussels, Belgium (2017), has the following learning objectives: define social marketing and understand the concepts of behaviour change for social good; analyse the social marketing environment; be able to select target audiences, objectives and goals; apply the basic and advanced techniques for development of social marketing strategies; develop price, promotion and place strategies for a chosen social marketing issue; understand how to effectively manage the implementation and evaluation of social marketing projects. Teaching and learning methods: lectures, small group exercises, tutorials, related information in the web, social marketing videos. The curriculum is developed for the year 2017, for one semester, lessons held twice a week.
The George Washington University, USA, School of Public Health and Health Services, Social Marketing: Theory & Practice (2007) -This course focuses on the use of marketing principles and techniques to develop population-based health promotion and disease prevention programs. The emphasis is on learning how to incorporate a marketing orientation to address the diverse range of issues and problems that are encountered in the modern day practice of public health. Course learning objectives: distinguish marketing approaches to public health from other theories and models; to learn basic and advanced techniques for developing social marketing programs; apply the marketing models and skills to problem identification, framing and planning; understand how to create environmental and policy change through social marketing programs; how to develop a marketing plan in a collaborative setting; understand the critical points for effectively managing the development, implementation and evaluation of social marketing projects. Methods of instruction: lectures, case studies, required texts, additional required readings, class and small group discussions, student presentations, other.
University of Wisconsin-Madison, USA, School of Medicine and Public Health, Introduction to social marketing, five day course (2013). This course provides students an introduction and orientation to social marketing and its specific applications in public health. Class sessions combine didactic presentations with group discussions and in-class exercises. Students are expected to read all assigned materials highlighted on the syllabus. Students are also expected to complete a small workgroup assignment for oral and written presentation. Upon completion of this course, students are expected to: define social marketing and its unique features as a public health and social change tool; identify appropriate uses of social marketing in public health; sequence the steps used in conducting a social marketing project for behavioural or social change; apply a model for developing, implementing and evaluating a social marketing campaign; think "like a marketer" for public health interventions.
University of North Carolina at Chapel Hill, USA, Social Marketing in Public Health (2017). The first part of the course is foundational, covering marketing basics, a look at public health in a market environment, an exploration of the limits of communication alone to effect change and an overview of several theories and planning approaches that the world social marketing community currently finds helpful. The second part provides an in-depth experience creating a social marketing plan to address a public health, safety or environmental issue. Upon successful completion of Social Marketing in Public Health, students will be able to: describe the rationale for integrating marketbased strategies into traditional public health program planning, implementation and evaluation, understand the limits of communications-only approaches to behaviour change, begin using marketing concepts and processes to develop interventions that create the social change for healthier communities, find resources to continue their formation as users of social marketing.
Financial University under the Government of the Russian Federation, Master's Program in Educational Management, Social Marketing, Moscow (Козлова, 2011). The aim of the discipline is the formation of skills to the students in applying the conceptual framework and technologies of marketing activities in the social sphere, principles of social responsibility and competence, methods of social partnership. Objectives of the discipline: familiarisation of the students with modern marketing concepts and technologies; with the particularities of social marketing in commercial and non-profit fields; mastering innovative marketing technologies in the social sphere; acquisition of practical skills of social competence in decision making.
Victoria University Wellington, New Zealand, School of Marketing and International Business, Social marketing course (2016). This course considers the planning and implementation of programmes designed to bring about social change using concepts and practices from commercial marketing. Course learning objectives: explain the scope of social marketing and how it relates to other areas of marketing; summarise how effective social marketing campaigns achieve desired social objectives; interpret why behaviour change is often difficult and the need to invest in long-term strategies; utilise the relevant theoretical frameworks available to social marketers to understand consumer motivations and reasoning; use the principles of marketing communication and persuasion in order to effectively influence targeted audiences and achieve objectives; critique ways the effectiveness of campaigns can be measured and explain the difficulties that may be encountered. Course learning objectives are to be met through attendance at lectures, presentations by guest speakers and students, course readings, participation in workshops/tutorials and the preparation of work for course assessment, both individually and in groups.

Methodology
The research is interdisciplinary, applicative, descriptive, with a qualitative approach, based on logical-deductive reasoning. The set of instruments proposed in this study were tested in 2019, on a group of master students (specialists in various fields, mainly medicine) in the second year of study at the School of Public Health Management, Nicolae Testemitanu State University of Medicine and Pharmacy of the Republic of Moldova. The master students were trained in social marketing during the Marketing Health Services course, by using the study program included in the Results/ Findings section. By using simulation, they developed a social marketing program by using the sketch of the team and the Social Marketing Guide described in this paper. In order to see the evolution of their social marketing knowledge, they completed a test before and after the course. At the end of the course it was held a focus-group discussion in which the trainees expressed their opinions and suggestions regarding the methods of training used, the information and materials provided and the guide content. Their feedback was used for adjustments.

Findings
Through this research it was highlighted the importance of developing social marketing in the field of public health in a total framework that comprises three dimensions: the political, training and collaborative ( Figure 1). Thus, the political dimension implies the unified application of the concept at the national level through the specific strategies and encouraging the program developers to use marketing techniques in order to influence the behaviour of the individuals regarding their health. The main tool that can be useful here is the guide for the implementation of social marketing, which would include the main concepts of the field and the steps that have to be followed in a practical approach to developing health promotion projects. Training dimension (courses for students, master students, specialists)

Implementation Guide Study Program Roles of team members
The training dimension involves conducting courses at different levels and stages: for students, master students, specialists (mainly in healthcare). The instrument that allows realising this dimension is the training program (curriculum) that is oriented on the formation of knowledge, attitudes and competences for the implementation of social marketing in the field of public health to the medical specialists. Between the two dimensions and between the two instruments there is a close connection, especially because their implementation should be carried out in parallel, in order to consolidate and channel the efforts in order to obtain measurable results. So there is needed a national vision completed by strategies, and at the same time those that have to put this into practice have to have the appropriate competences.
The training dimension is the central element, which involves the training of the specialists who will develop and implement health promotion programs, with the help of a curriculum. However, for the training to be carried out in a more practical framework, the use of the social marketing guide in simulation exercises is a useful training technique. The political dimension encourages the extension of the training dimension to different levels and stages. In this way, these dimensions influence each other and provide a broad framework for social marketing implementation, along with the collaboration dimension. The latter involves the creation of mixed teams and the clear distribution of the roles of each member, of which at least one should be a social marketing specialist.
Next are presented three tools elaborated in the context of the present research: the content of a social marketing guide for the implementation in the public health field of the Republic of Moldova, the program of the course Social marketing in health promotion, the sketch of the implementation team of a social marketing program.

Guide for the implementation of social marketing in the field of public health in the Republic of Moldova
Based on the study of the specialised literature and international guides in the field of social marketing, it was developed a guide for the implementation of social marketing in the field of public health in the Republic of Moldova. The main advantages of this guide are: -the short content of the material (too much effort is not required from the users), -it is the first such instrument available in Romanian language, -it is adapted to the national specific (through the examples used), -it presents a new model of implementing social marketing in public health.
The document was structured as follows: -Introduction to social marketing (defining the main concepts) -Model T for the implementation of social marketing in public health (basic principles, conceptual scheme and implementation stages) -Support sheets (sketches that can be used as a basis in the guide implementation process).
The guide was created following several steps: • Audience analysis: the guide is intended for specialists in the field of public health who intend to participate in the implementation of a social marketing program, but also for students / masters as a course support. In the process of developing the guide were taken into account the needs of each group, avoiding too technical and rigid language. At the same time, the volume of information was limited -in order not to get a guide that would take too much time to study. • Studying the processes of social marketing implementation: there are several models of social marketing implementation, but also guides available in English on the application of social marketing in the field of public health. The most useful and important elements have been taken over and adapted according to the new guide. • Collecting materials: tables and graphs were used for representativeness to facilitate the process of assimilating information. • Writing the guide: establishing the content, highlighting the main ideas, using an accessible language, checking the content and grammar and stylistic correctness. • Layout: A guide should be easy to use, but also attractive as these are the main features in the layout process.
• Testing: the guide was tested in a simulation exercise conducted with masters students from the School of Management in Public Health. Feedback from participants was used to improve the guide. Suggestions for using the guide: -Initially the guide should be read in full and then it will be welded and applied in parts.
-Although comprehensive and explicit, the guide should not be viewed as an exclusive tool. If necessary, other techniques or materials can be applied that will help to carry out a social marketing program. -The guide must be studied by all team members implementing a social marketing program to promote health, regardless of specialty or role.

The training program -Curriculum
For teaching/learning the concept of social marketing it is recommended to set up a separate course, with a duration of at least 8 academic hours. The course was designed for students from Nicolae Testemitanu State University of Medicine and Pharmacy of the Republic of Moldova, especially for the master students at the School of Public Health Management, but also for the continuous training of doctors at Nicolae Testemitanu SUMPh. Given the small number of hours it entails, but also certain difficulties in allocating space in the general curriculum, the course can be integrated within other disciplines, such as: Marketing health services, Management and marketing, Health promotion, Promotion of health and health education etc. It is important to mention that the program proposed here can be also used to train specialist teams before developing and implementing a social marketing program in the health field. The training program includes the most important components of an analytical program implemented at Nicolae Testemitanu SUMPh in accordance with the SM SR EN 9001: 2015/ ISO 9001:2015 Management System, namely: the purpose of the discipline, the training objectives (at the level of knowledge and understanding, application, integration), conditions and prerequisites, basic content, teaching and learning methods, evaluation methods.

The training program of the Social marketing in health promotion course
The purpose of the course: Under the conditions of a society in which the need for complex health promotion programs is felt, their success is directly linked to the possibility of inducing a long-term behavioural change, which can be achieved with the help of social marketing techniques. The purpose of the module is to familiarise the participants in the course with the field and principles of social marketing, to develop practical skills in the field and to encourage the application of social marketing in health promotion programs. The course is oriented towards the development of skills through interactive teaching-learning methods. The training objectives within the discipline: • At the level of knowledge and understanding: -Defining the concept of social marketing and delimiting other notions with which it is frequently confused (social media, social advertising etc.) -Description of the historical context of development of the discipline -Statement of the fields of application of social marketing -Identification of the components of the social marketing mix -Description of the components of the social marketing plan.
• At the level of application -Arguing the need to use social marketing in public health -Application of marketing research methods -Consumer segmentation according to multiple criteria -Using creativity in the development of exchange theory -Development of a promotion program -Organising a promotional action.
• At the level of integration -Implementation of social marketing campaigns -Demonstrating the usefulness of marketing in health services -Highlighting the role of social marketing in changing health behaviour.
Prerequisites and requirements: Knowledge of general marketing is required for studying social marketing.
Basic content of the course: -The social marketing concept and its components. Particularities regarding commercial marketing -Historical landmarks of social marketing development -Areas of application -Analysis of the current situation and selection of the target group -Behaviour change -Developing a mixed marketing strategy to promote health -Model T of social marketing development -Implementation and evaluation of social marketing campaign.
Teaching and learning methods used: -Semi-structured conversation: both the heuristic conversation (for generating personal ideas and opinions) and the catihetic one (to check if the information handed over has been stored).
-Cluster technique: used in evocation to highlight the associations that occur with the phrase: Social marketing used in behavioural change regarding health.
-Discussions and debates on the use of social marketing in public health. -Case studies: the teacher presents real health promotion programs implemented at national and international level, and participants are invited to find optimal solutions to certain problems. -The cube method: involves working in six teams with final discussions on the topic addressed. Each group has a task printed on one side of the cube: to describe the concept of social marketing, to compare social marketing and commercial marketing, to associate social marketing with other similar notions and performs the delimitations, to analyse how the 4 P can be used in social marketing, to apply the theory of change in social marketing to promote health, to argue for and against the use of social marketing in behavioural change.
-The snowball method: course participants are urged to identify and describe quantitative and qualitative marketing research methods that may be useful in social marketing. They work first individually, then in pairs, then in two large teams. Finally, the results recorded by each team are discussed.
-Brainstormin: students are proposed to develop a program to promote heart health using social marketing techniques. All ideas are noted on a Flipchart and can be used later in the simulation method.
-Simulation method: a development team of the health promotion program is formed, the roles are divided and the planning and implementation processes are simulated. -Creativity exercises: exercises of alternative use through which participants in the course seek other uses to certain common objects, such as: office clip, newspaper, CD and so on. In this way, they learn to look at things from a different perspective, a skill required in the development and application of social marketing.
Methods of evaluation: -Current: evaluation of the completion of the practical exercises and testing the theoretical knowledge obtained at lectures. -Final: elaboration and presentation of a health promotion program using social marketing techniques. Knowledge assessment test.
Recommendations regarding the training program: -flexibility in relation to the needs of the students (adjusting the examples and exercises according to specific conditions) -focusing on the practical side and less on the theoretical aspects -the use of different and interactive teaching-learning methods -highlighting the benefits of social marketing compared to other behavioural influence techniques.

The team for the implementation of a social marketing program
In the specialised literature, the importance of a multidisciplinary team in achieving the social marketing objectives is mentioned, but the responsibilities that each member has and the necessary knowledge he or she must have are not clearly described. We present below a sketch of a team in implementing a social marketing program, in which to each role is assigned a single unit. Where appropriate, the number of specialists may be increased in relation to the needs of the program. An important aspect revealed through this sketch is the need to hire both a specialist in the field of social marketing and one in communication. Although the two areas intersect at certain times, this fact must be reflected by a collaboration and not by a substitution of one of the specialists. As reported in Table  1, a social marketing program aimed at influencing a certain health-related behaviour should be developed by a team of specialists in various fields, in particular: health promotion, health education, medicine, social marketing, marketing research, communication, psychology, management and so on. Important aspects regarding the implementation team of a social marketing program: -Social marketing specialists cannot substitute those in other fields: communication, public health, psychology and so on. -It is necessary for each team member to be trained in the field of social marketing before the development stage of the program. -It is important for each member to contribute to the development of the social marketing program, not only at the implementation stage but also at the planning stage. -When certain disagreements arise or the inability to divide the duties and roles -the project manager must put the needs of the final consumer in the foreground. -Depending on the case, some services may be outsourced -such as marketing research, or technical ones (logistics, IT, etc.). The efficiency of the training program and the Guide for the implementation of social marketing in the field of public health in the Republic of Moldova were tested by the second year master students (group 1801) from the School of Public Health Management, who are current and future managers in the health system, potential participants in health promotion programs. They completed a multiple choice test at the beginning and at the end of the Marketing health services course that comprises 24 academic hours, out of which 8 academic hours of direct contact are allocated for social marketing applied in health promotion. The initial and final tests were completed by 16 master students, who had a presence of over 90% at the course. According to the results of the initial tests, an average score of 4.25 points was registered out of the total of 8, while in the final test an average score of 7.44 points was reached, ie an almost double score. Out of the total number of 8 points, 3 were assigned to questions in the field of social marketing. The initial results expressed an average of 1.2 points, and at the end of the course the average score was 2.85 points (95%).
At the same time, within a simulation exercise, a social marketing program on heart health was created using the team sketch and the Social marketing guide. Finally, through the discussions suggestions were collected regarding the possibilities of improving the guide, and the comments made by the participants were subsequently implemented. These referred to the technical writing of the material (numbering, page filling) and information supplementing (detailing the segmentation process in social marketing). The participants rated the guide as useful, accessible, well structured and succinct, and the overall course as being informative, practical and necessary for their professional activity.

Conclusions
The present study was designed to determine how social marketing can be developed in public health and to provide a set of practical instruments in this regard. The most obvious finding to emerge from this paper is that social marketing implementation in public health should be carried out via a total framework, that comprises three dimensions: political, training and collaborative. According to these dimensions a set of instruments was developed. The political dimension implies a unified application of the concept at the national level through specific strategies and encouraging program developers to use marketing techniques in influencing health behaviour. The instrument that can encourage the social marketing development at this stage is the Guide for the implementation of social marketing in the field of public health in the Republic of Moldova, developed and presented in this study. The training dimension implies courses provided at different levels and stages of training: students, master students, specialists. A curriculum in this regard was developed, that uses a mix of teaching methods and the basic concepts to be learned. The collaborative dimension requires the creation of joint teams and clear distribution of roles for each member, of which at least one should be a specialist in social marketing. A sketch of the team is proposed as an instrument, that shows the types of the specialists needed for social marketing programs and their responsibilities.
The study has gone some way towards enhancing our understanding of social marketing and it has several practical applications, especially by the instruments provided. The usefulness of the instruments is expressed by their possibility of being adapted to different context and situations, which makes them applicable elsewhere in the world.

Research limitations and future research
The instruments were adapted for the Republic of Moldova and some minor adjustments may be needed before implementing them in other countries, for example the Implementation Guide can be completed with some successful national programs or the study program could be adapted according to some national educational requirements, but the essence remains the same and can be utilised.
In progress is a study of the knowledge and attitude of medical students and public health specialists regarding social marketing. As a future research could be identifying the steps of social marketing strategy creation in accordance to the presented total framework (that comprises the national vision, the training necessity and the complexity of the teams).