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Branding in Urban Health Management: Overview of an Emerging Literature

Today, creating healthy cities has become the major challenge for both urban governance and public health management. Public health in urban context can be achieved through creative and new approaches such as social marketing and health branding. This review is aimed to introduce the application of health branding as a rather new but highly important approach to public health and an effective tool for preventive programmes of public health management. Branding strategies work particularly well in health campaigns that seek to spread awareness about the health issue. Adoption of branded ‘‘healthy lifestyles’’ increases the probability that individuals will engage in health promoting and disease preventing behaviours. Branding help health management with the mix of interventions and a planning model in order to change social norms and behaviours. In developing countries such as Iran, utilization of branding strategies in health management systems and services is really new and the true potential of social marketing branding has yet to be realized. effective tool for programmes of urban governance and public management. The first part of this addresses the implication of social marketing and in area. Subsequent discussion focuses on the intervention models and planning process can be applied by urban and public health management.


Introduction
In the 21 st century, there is more attention being devoted to public health concerns and to wider determinants of health (World Health Organization, 2002). Reconciling the growing proportion of the global population that lives in urban centers with the goal of creating healthy cities for all poses the major public health challenge of this era (Vlahov et al. 2007). Cities concentrate people, opportunities, and services including those for health and education (World Health Organization 2010, 2014; University College London et al., 2015). Besides, cities also concentrate risks and hazards for health. Cities tend to promote unhealthy lifestyles and behaviours, like convenient diets, sedentary behaviour, smoking, and the harmful use of alcohol and other substances (World Health Organization, 2010; University College London et al., 2015). The World Health Organization (WHO) identified urbanization as one of the key challenges for public health in the 21st century (World Health Organization, 2014). In order to effectively deal with these challenges, cities need quality intelligence on population health status (Caiaffa et al. 2014). A range of health and social services influence urban health including direct services such as education, health care and community-based supports, as well as governments' and health management capacity to respond to a wide range of public health threats that can strike urban centres (World Health Organization, 2000). Today, neither urban governance nor public ealth professionals appear to be doing well in improving the public's health (World Health Organization, 2002). Many public health programmes taken by public health management and urban governance are short term and focus their evaluation on process or outputs rather than changes in population behaviour (European Centre for Disease Prevention and Control, 2014). Substantive health gains for the population can indeed be achieved through new approaches to health promotion and disease prevention (World Health Organization, 2002). Urban context plays an important role in applying creative strategies and approaches such as health-related social marketing which has emerged as a prominent health promoting strategy to achieve and sustain behavioural goals (Elwes & Simnet, 2010) by understanding target audiences and making it easier for them to adopt behaviours that are life enhancing (Griffiths et al. 2008). Social marketing has been highly suggested as an approach to generating planned social change (Kotler & Zaltman, 1971;Sheth & Frazier, 1982;Fox & Kotler, 1980). It has been noted that social marketing may be especially useful in efforts to "change behaviours" (Fox & Kotler, 1980;Wallack, 1984 (Wallack, 1984). The objective of social marketing is to promote public health and Therefore its strategy is predominantly preventive (Birkinshaw, 1993). Social marketing is important for current paper because "it acts as a framework for the use of branding" (Long 2006) in health campaigns. This paper is aimed to introduce and discuss the application of health branding as a "rather new but highly important approach to public health" (Pralea, 2011) and an effective tool for preventive programmes of urban governance and public health management. The first part of this paper addresses the implication of social marketing and branding in health-related area. Subsequent discussion focuses on the intervention models and planning process can be applied by urban and public health management.

Social Marketing: Literature review and definition
The term "social marketing of health" was fallen upon by accident, says Manoff, during the 1960s as a useful distinction from commercial marketing (Grier & Bryant, 2005;MacFayden et al., 1999). Then it emerged as a discipline of study in 1970s when Philip Kotler and Gerald zaltman highlighted that the same principles used in generic marketing were being used to market or sell ideas, attitudes and behaviours (Vijayarani, 2016). An early definition of social marketing described it as using marketing principles to "influence the acceptability of social ideas" (Kotler & Zaltman, 1971). It has been suggested as an approach to generating planned social change (Kotler & Zaltman, 1971;Sheth & Frazier, 1982;Fox & Kotler, 1980). Contemporary writers define it as a method to influence "the voluntary behaviour" of target audiences (Perese et al., 2005; Lefevbere, 2011). The National Social Marketing Centre of U.K (NCMC) defined this terms as "the systematic application of marketing concepts and techniques, to achieve specific behavioural goals, for a social or public good" (National Social Marketing Centre, 2006). Social marketing seeks to move beyond just informing, increasing knowledge and understanding or seeking to influence people's attitudes or beliefs (European Centre for Disease Prevention and Control, 2014). It covers a variety of disciplines including health education, advertising, business management, scientific research, system analysis, community organization, psychology and epidemiology. The objective of social marketing is to promote public health and its goal is improved health for all. Its strategy is therefore predominantly preventive (Birkinshaw, 1993). So social marketing's focus is on behaviour and behaviour change. As indicated in Figure 1, social marketing analyses both problematic behaviour that needs to be changed and positive behaviours that need to be encouraged and supported. Social marketing works to develop interventions that remove or reduce barriers to positive health behaviours (European Centre for Disease Prevention and Control, 2014).

Fig 1. Incentives and barriers to behaviour change (European Centre for Disease Prevention and
Control, 2014; National Social Marketing Centre, 2007) Promoters and detractors of social marketing may both agree on the ultimate goal of achieving behaviour change in target populations; however critics of social marketing have argued that behaviour change is difficult to achieve solely through the mechanisms adopted by social marketing (Firestone et al. 2017) because many health behaviours are complex and health behaviour change is a difficult process (Evans et al. 2008). There are arguments that social marketing cannot simply adopt commercial or generic marketing approaches, but should develop its own terms and concepts to drive the discipline forward (Rademeyer, 2014). Use of branding principles in social marketing is a proven approach to encouraging voluntary behaviour change (Newton-Ward et al. 2004). Making the use of effective branding strategies is a key object for public health (National Social Marketing Centre, 2007). The findings of Evans et al. indicate that behavioural branding is an important public health strategy (Long, 2006). The application of Branding strategies can help social marketing in highlighting desired behaviours and their incentive and rewards to targeted audience. Therefore, According to Hastings (2007) a research of UK's National Institute for health and clinical excellence stated that branding can be effective way to influence health behaviours (Prale, 2011).

Branding in Social Marketing and Health Campaigns
Branding has traditionally been associated with commercial products and services, however, health communication practitioners are beginning to realize that branding principles are also relevant to people, places, ideas and messages surrounding health issues (Keller, 1998;Long, 2006). One hypothesis underlying public health branding as a social marketing strategy is that adoption of branded ''healthy lifestyles'' increases the probability that individuals will engage in health promoting and disease preventing behaviours. However, The strategic use of brands and branding in public health, based on behavioural theory, to change specific knowledge, attitudes and health behaviours is relatively new (Evans et al. 2008). The "brand" has been one of the key concepts in commercial marketing in the past decades (Pralea, 2011). It has played a key role in marketing strategies and it has been defined by the American Marketing Association AMA as it follows: "A brand is a name, term, design, symbol, or any other feature that identifies one seller's goods or service as distinct from those of others" (American Marketing Association, 2007; Maurya & Mishra, 2012). However, Branding means more than just giving name and signaling to the outside world that such a product or service has been stamped with the mark and imprint of an organization (Maurya & Mishra, 2012). The understanding of brand, essentially, as a social construction contests the conventional definition of a brand as "the sum of individual perception" and suggest instead that brands are "a shared reality, dynamically constructed through social interaction" (Aitken & Campelo, 2011). Therefore, the goal of branding is to create an emotional connection between a company and its consumers (Lovie, 2015). Branding fulfils an important purpose in establishing meaningful connections and even a sense of community with target audiences through the making of mental associations and emotions (Gordon et al. 2016). This is useful for social marketing, which is often focused on long-term behaviour maintenance. Keller (1998) argued that branding perspectives and principles can be useful in a social marketing context to address public health problems (Keller, 1998). Newton-Ward, Andreasen, Hastings, Lagarde and Gould (2004) took a stance similar to Keller's (1998) argued that branding strategies can strengthen the position and practice of social marketing (Long, 2006). Despite the utility of branding as a marketing tool, the application of branding in social marketing is often underdeveloped (Gordon et al. 2016). Evans et al. (2007) defined public health brands as: "the associations that individuals hold for health behaviours or lifestyles that embody multiple health behaviours" (Pralea, 2011). Just like commercial brands, public health brands succeed by competing effectively with other brands in their market space. But rather than competing with other brands in the same line of products or services, they compete with unhealthful commercial messages and other social influences (Rademeyer, 2014). Branding strategies has emerged as a top management priority in the last decade and they can be used by public health management too (Keller & Lehmann, 2006). Branding strategies work particularly well in health campaigns and health organizations that seek to spread awareness about the health issue. Linking the health issue to a visual symbol and slogan will help to create a brand identity that the target audience can easily associate with the health issue. Once enough member of the target audience are aware of the health issue, the brand may also serve to remind people to engage in a behaviour, maintain a behaviour, or support the health issue (Long, 2006). Public health brands use well known techniques such as modeling socially desirable behaviours (i.e., being socially accepted by not smoking) and imagery (e.g., being hip or cool by exercising) to encourage emulation of healthy behaviours (National Institute for Health Care Management Foundation, 2009). Branding played a pivotal role in three effective social marketing campaigns from the United States (US) , namely, The Heart Truth campaign that sought to raise heart disease awareness and prevention among women (Long et al. 2008); the VERB campaign that was designed to increase physical activity among children aged 9 to 13 years (Wong et al. 2004); and the TRUTH campaign that pitted itself against tobacco manufacturers as a non-smoking lifestyle brand for teenagers (Evans et al. 2002). It is anticipated that the knowledge acquired from these campaigns and other literature on brands in social marketing will lead to the emergence of a single term with a related definition and role, which will ultimately deepen knowledge on social marketing and the creation of effective campaigns (Newton-Ward et al. 2004).

Health branding interventions
A social marketing and health branding programme will normally consist of a mix of interventions. To select the optimal mix of interventions it is important to rely on research evidence and data collection. One of the most important interventional framework used in marketing focuses on the Four Ps of marketing mix including product, price, place and promotion (European Centre for Disease Prevention and Control, 2014). These so called "4Ps" have been the object of vigorous research activity in the business and commercial sectors, but have only recently been discovered by the health promotion field (Lefebvre & Flora, 1988) and The U.S. Department of Health and Human Services (2002) stated that the 4Ps can be applied to social marketing and health campaigns (Donovan & Henley, 2010). Along with the 4Ps of the marketing, Nedra Weinrich in her article mentions that social marketing and health branding campaigns requires a more focused marketing mix and a few more P's are added along with the traditional 4P's (Vijayarani, 2016). As indicated in table 1, these 8P's should be considered before starting the health branding process. Defining these elements help the health management practitioners to have a comprehensive view about the health branding process.

Public
External and Internal groups involved in the social marketing, External public contains the target audience, the policymakers, audience directly or indirectly related to target audience. Internal public includes people directly and indirectly involved with approval or implementation of the program (Vijayarani, 2016).

Partnership
Identifying and working with other organizations/ groups -government or private or NGOs or Self-Help groups -with similar goals (Vijayarani, 2016) in order to increase accessibility and demand

Policy
The involvement of government and some policy changes by them in order to achieving campaign's goals especially for social issues like smoking (Vijayarani, 2016), using media advocacy to encourage policy change Purse string Where you will get the money for your program and who the involved stakeholders are (Vijayarani, 2016).

Process of health branding and social marketing campaigns
Like generic marketing, social marketing and health branding should have a long term outlook based on continuing programmes rather th an one-off campaigns (MacFayden et al. 1999). Health management need to determine a comprehensive process for changing behaviours. We should notice that social marketing and health branding programmes does not follow fixed, predetermined path. The direction and process take will depend upon the knowledge of the problem that is accumulated. The more thoroughly the plan is prepared, the more easily it can be implemented (Birkinshaw, 1993). Figure 2 shows the social marketing and health branding process can be applied by public health management and other social practitioners. The stages of the social marketing process will be familiar to anyone who has been involved in project or program development. However, the National Social Marketing Center highlights in particular the importance of the scoping stage-it drives the entire process. The core marketing principles, the four Ps (or 8P's), are at the heart of this process because they are used at the initial planning stage (National Social Marketing Centre, 2007). It's important to note that the process of developing a social marketing program involves research at every stage, with constant reevaluation to assess whether the program is on track (Weinreich, 1992).

Discussion
Health branding is a rather new but highly important approach to public health campaigns (Pralea, 2011). A branded social marketing campaign is focused, and it uses brand symbols, logos, slogans and brand communication consistently throughout all campaign materials and messages (Long, 2006). As with any other types of marketing, social marketing and branding strategies cannot be expected to resolve every single type of health problem (Vijayarani, 2016). Social marketing and Health branding are not the only method of health education and promotion and are only appropriate in certain circumstances. They have many limitations and challenges such as the ambiguity in branding concept and process, the scale of interventions, communication problem (e.g. public relation and advertising), structural barriers in targeted country or community, ethical issues, funding and lack of support for programs (Birkinshaw, 1993;Bloom& Novelli, 1981;Pondichery, 2014). Moreover, some authors such as Vikki Spruill (2004), mentions in The Chronicle of Philanthropy, that Branding has negative effects on social marketing. Instead of helping charitable groups and campaigns to work as one and develop a support base consisting of activists, donors and volunteers, branding turns out to be an obstacle. It promotes unhealthy competition amongst the nonprofit organizations for increasing their awareness and visibility. Another drawbacks of using a branding strategy for a public health campaign include the cost and length of time required for a brand to gain awareness and for a shift in attitudes and social terms to take place, as well as the difficulty of evaluating actual behaviour change. In spite of the criticism against branding social marketing, it is important to note that branding brings in effective response in terms of program implementation and in creating an awareness, interest and fund generation (Vijayarani, 2016).

Conclusion
In the recent years, many social marketing brands and health have applied branding interventions and principles to "encourage adoption of health behaviours and avoidance of risk behaviours" (National Institute for Health Care Management Foundation, 2009) among the community Such as the truth, and the "stand" anti-tobacco brands, and also the VERB physical activity. However, examples of successful social marketing branding remain the exception and the optimal use of branding in social marketing remains a major challenge (Gordon et al. 2016). Branding theory and practice within social marketing is arguably only partially developed, with few examples of branding applied to behaviour change available in the literature (Vijayarani, 2016). In developing countries such as Iran, Health branding and social marketing theory and practice is really under-developed. In Iran, few studies have been conducted about the application of social marketing in health (Rezaei-Pandari & Keshavarz-Mohammadi, 2014) and the concept of health branding is relatively new and often confused with health care marketing or health tourism branding. In current paper an attempt is made to introduce health branding approach in social marketing campaigns and how it can assist urban governance and public health management in preventive strategies and managing social and health behaviours. It is worth mentioning that utilization of branding strategies in health management systems and services is really new and the true potential of social marketing branding has yet to be realized.