We are one, and we are many: the new coalitions driving progress in health promotion
Times have changed, and experts including Professor Jeff French say social marketing and broad-based coalitions of influence are the new way forward for health promotion.
Professor Jeff French is one of the pioneers of social marketing, an approach to sustainable behavioural change that combines a deep understanding of community needs with the effective application of marketing strategies. He argues that efforts to improve health literacy, health services, or health equity, will increasingly need to recognise the agency of individual community members, while being powered by coalitions that include government and non-government bodies and ‘new’ players from the private sector. In this conversation, he highlights the need for negotiated wellbeing goals, more facilitatory leadership and a systemic application of social marketing.
Q: You have written that the ‘big state’ approach to promoting better health outcomes has passed its zenith. Strategies that rely on a one-way flow of information from experts to the public no longer work. Today, the public and other players, including for-profit organisations, should become partners in health campaigns and ‘co-create’ interventions. Why do you think there has been this shift?
Professor Jeff French: It’s a confluence of factors. We have seen a developing access to information and connectedness through new technologies, and more of a ‘consumer’ cultural response to the provision of services, be they from the private sector or NGOs or from government agencies. People expect more, they demand more. They’re more discerning and they’re more vocal in their criticisms.
There has also been, on a global basis, a big fall in trust in all forms of authority. It’s not the landscape of 30 or 40 years ago, where there was a lot of respect for experts and people in positions of authority and power. Now, we’re much more questioning of what they’re doing. Previously, only those with power and expertise understood the issues deeply. Well, that relationship has shifted. Power has flowed from power elites to citizens. I think that’s something to be celebrated.
Within individuals and communities, there’s a huge amount of understanding about problems, their causes, what some solutions might be, and what interventions won’t work. We should be engaging people with the co-investigation of health issues and the co-creation of solutions. The old approaches, where you seek to drive down change through a community, based on that elite view of what the solution is, it’s not a tenable strategy anymore.
"The old approaches, where you seek to drive down change through a community, based on that elite view of what the solution is, it’s not a tenable strategy anymore."
Q: But there is still a role for experts?
French: Oh absolutely. If I’m going in to have some surgery, I want somebody who knows what they’re doing! There is a role for professionals [in health interventions]. We’re lucky that we’re getting increasing specialisation. We’ve got people who really know an awful lot about specific areas of expertise, and obviously we want to feed that in. But it’s more of an equal conversation now [with the public], than it has been in the past.
Q: And that includes understanding how individuals and communities want to define their wellbeing goals?
French: I think in terms of wellbeing, we probably need to incorporate more of what people perceive as wellbeing. You know, they may want to trade off that extra couple of kilos for the enjoyment that they get through eating chocolate. Dictating our epidemiological ideals to people, it's not the most effective strategy. You know, I'm a public health person. I want to reduce heart disease and cancer rates. And, of course, that's our bottom line. But I think we need to negotiate our way to that.
Q: You have said that social marketing is about ‘the creation of value for citizens’. What do you mean by that?
French: Social marketing is about understanding what people value and trying to create social programs that create that value for them. Why would you do something? Why do you choose to do something? Because you get some benefit from it in some way. It may be personal benefit, [something that makes] you feel better. Or it might be something you feel will help society, so it’s an altruistic value.
I mean, value can be created by restricting freedoms, too. If we all collectively agree that wearing seat belts is a jolly good idea, then we're prepared to give up some of our freedoms and maybe even face the prospect of being fined or put in prison if we don't do it. It’s voluntarily, collectively agreed: basically a trade-off between a restriction and some big social value. So, when I say ‘value’, that's what I mean.
Q: You have suggested health promoters should be in the business of ‘cross-sector facilitatory leadership’, and find ways to draw together coalitions of different partners.
French: Yes. Where we’re going with these trends is moving away from a leadership style which is about ‘I’m in front, follow me, I’m going to be the spearpoint of this change’, to one that’s adopting more a facilitatory leadership strategy.
It’s about making sure that all the assets that exist in a community to tackle these problems are leveraged and coordinated as far as possible. It’s about going from ‘follow me’ to ‘facilitation’.
"We’re moving away from a leadership style which is about ‘I’m in front, follow me’."
Q: How important is it for health promoters to work alongside for-profit organisations, and what issues might need to be managed in that relationship?
French: I think you’re implying here that it’s a kind of delicate, potentially tricky area to work in. But part of it is about who do people trust, who do they relate to. Many of the big brands out there have higher trust ratings than governments do amongst the population, particularly some of the people that are at higher risk of chronic disease associated with lifestyle [behaviours].
The scale of the interventions that we need to deliver, and the multiple intervention points we need to have to create change in these complex challenges, requires that we engage with partners that have the access and the ability to influence people’s behaviour.
I think you have to enter into those kinds of relationships in a very structured way and a very strategic way. You must understand your potential partners and open up dialogue with them early on in the planning process, to see where there are grounds for mutual benefit and the possibilities for collaborative working.
That means a real investment in making that work. Effort has to go into identifying potential partners, sifting them, [regarding their] suitability and compatibility with the overall program goals and, then, developing joint bits of action.
Q: How do you propose the sector work with groups that campaign against public health interventions like vaccination or fluoride in tap water?
French: Well, part of the process is also identifying the people who are the competition [to an intervention] and who you are not going to be collaborating with. You actually want to reduce their influence in some way.
There are some people who we can’t persuade to get on board and work with us. What we need to do is be clear about that and say, ‘OK, these people here in the middle are neutral and we can maybe work with them a little bit. These other people we can really build some collaborative interventions with through a long-term strategy. And these people over here are our foes’. And our job here is to just reduce their influence or eliminate them if possible. I’d include the tobacco industry and [various] peddlers of misinformation in that category.
Q: Is there a prejudice in the public health sector against working with commercial organisations?
French: In the past, if you talked in a public health institute about working with the private sector, the shutters would go up, because ‘we feel that they’re just bad people and they’re part of the problem’.
What we have to do is recognise that the vast majority of them are not. They want to do good things and create a licence to operate and be supported by communities. And I think we just need to have more conversations and start opening up this space and look for synergies.
It’s very difficult sometimes to lift off your personal prejudices against people or organisations. But sometimes, maybe if we do that, we can help people.