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Journal of Medicine and Life Vol. 11, Issue 1, January-March 2018, pp.15-19
Health marketing and behavioral change: a review of the literature
Cristina-Mihaela Chichirez, Victor Lorin Purcărea
“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
Correspondence to: Cristina - Mihaela Chichirez PhD Assist
Department of Marketing and Medical Technology
“Carol Davila” University of Medicine and Pharmacy Bucharest
8, Eroilor Sanitari Boulevard, 050474, Bucharest, Romania
Phone: +40742814902, E-mail: chichirez.cristina@gmail.com
Received: February 20th, 2018 – Accepted: March 26th, 2018
Abstract
Health marketing as a part of social marketing, must influence individuals, voluntarily, through various social programmes, in order to
accept, reject, modify or abandon a behavior in favour of a healthier lifestyle.
Acting on individual behavior change, social marketing can influence the behaviour of those who decide public policies, with positive
effects in social change. In time, in order to understand and predict a behavior, a number of theories, models and tactics were
developed with the aim to identify factors and mechanisms with the greatest impact in the changing process.
Cognitive- social theories proved to be more effective, because they offer guidelines for conducting research in behavioral change.
Keywords: behavioral change, health marketing, lifestyle, social marketing.
Health marketing is the component of Social
Marketing which uses commercial marketing principles
and techniques to influence a target audience, so as, on a
voluntary basis, individuals may accept, reject, modify or
abandon a behavior for their own benefit , groups or for
society as a whole [1]. Moreover, it is assumed that social
marketing is not a new concept, it even ocurred before
commercial marketing. In U.S.A., if for commercial
marketing, its beginnings are considered to be around
1900 [2], the social marketing principles have come
forward since the second half of the 19th century, as for
example, in the abolition of slavery in 1862, then in the
right of women's suffrage and the abolition of child labor in
1869 [3].
The concept of social marketing has been
introduced for the first time, in the academic literature, by
Philip Kotler and Gerald Zaltman, in Journal of Marketing.
Social Marketing describes ʺuse marketing principles
and techniques to identify a social issue, idea or behavior"
[4].
In recent years, the interest in social marketing
has increased, with a special interest in social issues
related to public health, prevention, environment,
community development and welfare [3]. Also,
MacFadyen and collaborators state that social marketing
provides the necessary tools to address these problems
by influencing individuals with the purpose of adopting
new behaviors and healthier lifestyles [5]. For instance,
social marketers had as main objective in U.S.A.
influencing the behavior of volunteer individuals in relation
to reducing obesity, smoking cessation, encouraging
walking, cycling and in Africa, the focus moved to solving
some major health problems, such as the prevention of
malaria, poliomyelitis eradication, decreasing infant
mortality, stopping the spread of HIV/AIDS.
At the same time, social marketing can influence
the behavior of those who decide public policies and of
those belonging to various interest groups, with positive
effects in social change, including law, public policy, and
community involvement, educational curriculum, business
practices, and others [3].
Rob Donovan and Nadine Henley mention the
fact that influencing individual behavior has the power to
determine a behavior change of those people who can
facilitate other behaviors and can may elaborate on
institutional policies and legislative changes in the social
structure [6].
Although there are similar principles and
techniques implemented, between commercial and social
marketing there are a number of differences. Thus, while
commercial marketing is aimed at the sale of goods and
services, which bring profits for the organization, social
marketing seeks to sell a change in behavior for the
benefit of the individual and society.
In their work entitled "Social Marketing. A
synopsis by the Center for Social Marketing ",
MacFadyen, Stead and Hastings highlight the types of
behavioral change produced by the social marketing . So,
on the short term, at the individual level may take place
behavioral changes, at the level of the group of individuals
may be registered changes in the rules and administrative
policies and at the level of society, may be registered
changes in public policies, respectively [5].
Journal of Medicine and Life Vol. 11, Issue 1, January-March 2018
16
On the long term, the level of the individual
changes occurs in lifestyle, at the level of the group of
individuals, changes may occur in organizations and at
the level of society, change may take place a social and
cultural environment. Also, specialists consider that social
marketing is much more complex than commercial
marketing regarding the following aspects:
the products of social marketing are much
more diverse;
the application of products is different from
individual to individual;
target groups are much more difficult to attain;
the involvement of the consumer is much
higher;
the competition is much more subtle and more
varied.
A major feature of Social Marketing is that of
recognizing positive behaviors more than the punishment
of the negative ones by forms of influencing economic or
compelling.
Social marketers can not promise effects and
immediate benefits in exchange for the adoption of the
proposed behavior, but they may determine the target
audience to take action in the following directions [3]:
to continue with the healthy habits;
to accept a new behavior;
to reject a potential undesirable behavior;
to modify a current behavior;
to abandon one of the old undesirable
behavior.
Some experts consider that along time, the
financial resources of individuals have made unhealthy
habits to become normal and therefore it is necessary to
support behavioral changes with respect to modifying
their lifestyles, stopping unhealthy habits, by
establishment of new habits, build physiological
resistance to their unhealthy needs.
Due to the fact that the negative effects of the
behaviors on health status are more visible, a series of
policies and strategies have been drawn up to change
them. At the same time, it should be taken in
consideration that health has multiple determinants, of
genetic origin, psychological, social, economic factors
which interact and determine determining their outcome
the behavior of the individual [7].
In their work "Theory and Research in Promoting
Public Health”, Wills and Earle identify three levels at
which behavioral change may operate: at the biomedical
level, behavioral level and at the social level [8].
Because behaviors are extremely complex, the
specialists have drawn up a series of theories, models
and tactics with regard to the understanding and
prediction of behavior, as an alternative to the model of
the biomedical device which dominates public health.
According to this concept, disease is explained by the
cause-effect relationship, stimulus-feedback, while the
operations to change behavior is based on the
measurement of the attitudes, the perceptions of the
target group [9].
Theories, models and tactics presented in the
scientific literature, can identify factors and mechanisms
with the highest relevance to a specific behavior and
provide interventional strategies and programs which may
trigger [10].
Theories are designed to simplify the elements
and phenomena encountered in the environment, giving
them an intelligible form [11], and it is necessary to know
the factors which affect them, the relations between
variables and the circumstances in which these
relationships occur or not [12].
Consequently, they are made up of a series of
interrelated concepts and definitions which gives an
overview of events and situations, thus facilitating their
understanding by specifying the relations established
among variables [13]. Models are descriptions based on
hypothetical analogy, foremost, explaining in detail the
phenomenon, and in fact, being part of the theory [14].
Moreover, the concept is the basic element of a
theory, and the operational form of the concept is called
variable. In theory, many associated concepts form a
construct [15].
Behavioral theories were divided into continuous
theories and stadial theories [16]. Continuous theories are
based on the identification of variables that influence
action and work under several combinations which
produce a single prediction outcome in the shape of an
equation for all individuals [17]. Stadial theories involve
multiple stages and a number of conditions by which
some individuals may be motivated enough to move from
one stage to the other [18].
From all continuous major theories, the most
important theories are those which offer social, cognitive,
and theoretical framework for research and in addition
select variables involved in the health and development of
the most effective prediction of the individual's motivation
for interventions in adopting a certain behavior [19].
The most important behavioral change model is
Bandura`s called Social Cognitive Theory, based on the
principles of social learning, which state that children’s
and adults' social-cognitive experiences are reflected in
their behaviors [20]. The theory was first developed by
Rotter [21], known as "Social learning theories” that rely
on stimulus-response theory. Bandura as well as social-
cognitive theory advocates argue that impulse received
from the feedback of an individual is not enough to
explain the whole human behavior. Thus, in his work
"Social Foundation of thought and action of social-
cognitive theory", Albert Bandura defined behavior as the
result of interaction between the personal factors
(personal effectiveness), and environmental action [22]. In
2001, Bandura mentioned that "internal factors of
personal nature in form of cognitive, affective and
biological events, behaviors patterns and environmental
Journal of Medicine and Life Vol. 11, Issue 1, January-March 2018
17
influences operate as factors that are influencing each
other" [23].
Personal effectiveness is considered to be the
strongest predictor of behavior and is used in Behavioral
Research studies and in health education for health [24].
Further, personal effectiveness expresses a
person's confidence in his requested abilities for the
adoption of a new behavior through actions concerning
the consequences of the situation, expectations, social
and environmental norms.
Motivation and action are governed by forward-
looking thoughts that include expectations regarding the
consequences of the situation, expectations regarding the
action and efficacy expectations. To perform a specific
behavior, first individuals must know it and their ability to
meet a series of behaviors is called "behavioral capacity".
In 1967, in his work, "A behavior theory approach
to the relation between beliefs about an object and
attitude toward the object", Martin Fishbein, developed the
Theory of Reasoned Action, suggesting that attitudes
influence behavior and that the best predictor of a
person's behavior is the intention to act [25].
Together with Icek Ajzen in the work "Belief,
attitude, intention and behavior: An introduction to theory
and research" (1975), he developed a structure for the
analysis of the interaction between the attitudes, beliefs
and behavioral intention [26]. However, they concluded
that the behavior is more influenced by the so-called
subjective rules, namely the individual's perception of how
others relate to the behavior in question [27].
Consequently, in 1988, Ajzen expanded and
revised the Theory of Reasoned Action by adding a new
predictor variable called the Rerceived Behavioural
Control, resulting in "Theory of Planned Behavior". This
addition takes into account the fact that the individual
wishes to adopt a new behavior when he has a positive
attitude towards a situation and he perceives that situation
to be important and beneficial for him and believe that he
would be successful in adopting that behaviour. Thus,
theory is based on cognitive behavior, without taking into
account emotional variables [3]. Ajzen justified the
importance of this predictor in the individual's motivation,
explaining that if there is no perceived behavioral control,
the attitude towards the behavior and subjective norms
are not capable to generate a sufficient motivation, to
trigger an intention [28].
In the late 1950s, Paulo Freire, a Brazilian
teacher who wrote 20 books about pedagogy and
education, initiated a program of education for the
residents of the slums and the people living from rural
areas, putting the basis for "Liberation Theory “[29].
The theory was later developed by Greenberg
(1978) and Wallerstein and Bernstein (1988), focusing on
education and empowerment (freedom of informed
decision making).
In his work "How does a language acquire
gender markers", Greenberg (1978) mentioned that health
education has the role to " determine people to make
informed decisions about their health, based on their own
needs and interests, as long as their decisions not affect
the needs and interests of other members in the
society."[30].
In the work "Empowerment education - Freire's
ideas adapted to health education", Wallernstein and
Bernstein emphasized personal empowerment, defining it
as "a social process that promotes the participation of
individuals, organizations and communities in the exercise
control over their own lives and the community in general.
From this point of view, empowerment is not the control
exercised over other people's behavior, but rather the
ability to act with other members of society to make a
changeʺ[31]. Also, Wallernstein and Bernstein mention
that three different stages which individuals need to follow
along the changing process
In the first stage, the information from the target
population is gathered, the needs of the community are
prioritized and an action plan is drawn up. The difference
is methodology meaning that information is not collected
and prioritized by marketers, but by the target population.
The second stage follows the education itself, based on a
dialogue between marketers and the target population,
marketers helping participants to elaborate their problems
and action plans. In the third stage, the plans of the target
population are implemented, followed by their monitoring,
re-evaluation and review.
This theory has the advantage of responding
directly to the needs of the community, identifying issues
by needs. A disadvantage is the fact that large groups of
people are working, which makes coordination more
difficult.
The model of trust in the health has been
developed by the social psychologists Godfrey H.
Hochbaum [32], Irwin M. Rosenstock [33] and Victor J.
Stretcher [34] and is a systematic method to explain and
predict the preventive behaviors, in fact these specialist
improved the work of Kurt Lewin [35].
Kurt Lewin proposed an approach of change by
analysing the opposite direction forces, namely,
generating change forces and forces resistante to
change. He described the change in humans by using to
the shape of an ice cube which consists of a several
status changes such as the melting of ice, passing
through the liquid phase and freezing water in a different
form.
Lewin considered that the change has must
imposed and the resistance to change can be managed
by setting out the objectives at the beginning of the
process which define the direction of evolution.
In the beginning, the model of trust in health has
been used to understand the preventive behaviors,
afterwards it was used to differentiate between a
favorable behavior and a conduct harmful to health,
respectively for the understanding of the related psycho-
Journal of Medicine and Life Vol. 11, Issue 1, January-March 2018
18
social behavior determinants of the favorable or
unfavorable health, which includes six variables [36;37]:
perceived susceptibility (the perception affecting
health is conditioned by a certain fact);
prediction of the severity of the consequences
(the belief of a person that the effect of a disease
or a status will pass if he acts );
the benefits of the adopted behavior;
the costs and barriers perceived in action (the
existence of a reason for why the behavior could
be perceived as incompatible, expensive, painful,
unpleasant or unstable);
the motivation to act ( internal or external
strategies which might be required for the
adoption of the behavior);
the motivation for health (the individual must
benefit from a series of impulses to convince him
to change).
According to this model, once an individual
perceives a threat to his health and the simultaneous
presence of the action for the assessment of the healthy
behavior, brings an advantage, he will act to favorable
change favorable.
Another model concerning behavioral change is
the Transtheoretic Model elaborated in 1979 by James D.
Prochaska [38] and then improved it in 1982 together
with Carlo C. DiClemente [39]. The development of the
model is based on the principle of identifying the stage in
which an individual is, each stage being defined by his
previous behavior and future plans.
In the work "Changing for good", Prochaska and
collaborators [40] describe the six stages of behavioral
change, and eventually remove the last, as follows:
1. precontemplation (the individual does not
intend to change his behavior and do not
recognize that he has an issue);
2. contemplation (the individual realizes that he
has a problem and begins to think about it,
accepting the opportunity to make a change in
his behavior);
3. preparation (the individual plans his actions
with a perspective on adopting a new
behavior);
4. action (the decision to change has been taken
and the individual operates in the direction of
adopting the new behavior);
5. maintaining (actions are directed towards the
stabilization of the new behavior and the
prevention of bad behavior);
6. completion (new behavior is strengthened and
there is no longer a danger to return to the old
habits).
In their work "Stages theories of health behavior:
The conceptual and methodological issues", Weinstein
and collaborators (1998) identified four characteristics of
the stages of changing behavior:
the stage description process;
the stages must be arranged in a certain
order;
in the same stage, obstacles should be
common;
in different stages, the obstacles may be
different.
The transtheoretic model aims at adopting
healthy behavior or giving up a bad behavior as a result
of a singular, rational and perfectly conscious decision of
the individual. It was originally designed for the treatment
of the drugs and alcohol, but then it has been checked
and on other behavioral patterns in education and health.
These theories and models have a special
importance for social marketers, helping them to identify
the key and intervention mechanisms in the social
marketing programs.
Due to the high degree of complexity which
behavioral change implies, generally, one theory is often
insufficient, and there are several theories which need to
be synthesized in order to determine a strategic pattern to
have the desired outcomes.
Conflict of interest
The authors declare that there is no conflict of interest.
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