Key concept 3: Competition
Competitive factors are those that get in the way of positive behaviours; e.g. like not using condoms for HIV prevention because they are perceived as ‘unmanly’, thought to reduce pleasure and/or not affordable or easily available. Competition analysis examines both internal and external competitive factors as well as barriers and enablers that impact on behaviour. Internal competition includes psychological factors, pleasure, desire, and risktaking whereas external competition includes wider influences and influencers on behaviour, promoting and reinforcing alternative or negative behaviours. Social marketing seeks to remove or reduce competitive barriers; e.g. by providing vaccination services in evening hours or at day care facilities within work places which can reduce the need for parents to take time off work to get their children immunised.
Competition can come from external sources such as cultural norms or economic factors but also from internal competition associated with people’s preferred or learned behavioural responses such as many people’s preferences for inaction or the avoidance of loss (see Table 1).
Table 1. External and internal competition factors
- External competition > Internal competition
- Social influences > Over-confidence
- Cultural influences > Temporal discounting (value the immediate over the long-term)
- Media influence > Loss aversion
- Physical environment influence > Pleasure and temptation
- Economic influence > Lack of effort
- Close family and friends influence > Habit
- Availability of services or products > Addiction
- Systems barriers > Biological drives
Social marketing also works to counter forces that actively seek to promote resistance to recommended behaviours. To this end, it develops an analysis of these forces and actors, and identifies strategies to reduce their influence.
Example: In some instances, public health authorities inform their clients about ways to read scientific reports and actively identify inaccurate web-based vaccination safety information and counter misinformation. 
Key concept 4: Behaviour – behaviour theory and behavioural goals
Behaviour theory is used to inform and guide all social marketing interventions. Through a broad behavioural analysis we get a fuller picture of the current behavioural patterns and trends to make sure that the incentives and barriers associated with both the ‘problematic behaviour’ and the ‘desired behaviour’ are fully understood.
Example: An analysis of obstacles to MMR vaccination uptake amongst Roma populations in Bulgaria  revealed:
- Challenges associated with the target group´s knowledge, attitudes and behaviours > Poor awareness and knowledge of antigens and diseases they protect from (including measles). Repeated visits are required to meet requirements of the national vaccination schedule. Competing priorities lead to missed vaccinations. Worries and misconceptions about side-effects and safety of certain antigens.
- Challenges related to being able to communicate effectively > Low literacy and numeracy, language ability and health culture among vulnerable populations (e.g. Roma). Low self-efficacy of Roma vis-a-vis medical practitioners and institutions.
- Challenges related to creating circumstances that make it easier for the target group to take desired action > Lack of trust between caregiver and primary healthcare physicians. Poor ability of primary healthcare physicians to communicate effectively with Roma. High opportunity costs associated with repeated visits to general practitioners (GPs).
Once you have clearly understood the current behaviour, you can start developing and testing all possible interventions designed to encourage and maintain desired behaviour, and interventions designed to influence problematic behaviours. The specific behavioural objectives are set out in SMART format: Specific, Measurable, Achievable, Reliable and Time bound. Example: In some instances, public health authorities inform their clients about ways to read scientific reports and actively identify inaccurate web-based vaccination safety information and counter misinformation. 
Specific: Precise – not open to different interpretations; Measurable: Can observe and collect objective measures; Achievable: With the resources available; Reliable: Consistent, relevant, can be gathered; Time bound: Measured within the time frame of the intervention.
Key concept 5: Audience segmentation
Segmentation is the division of an audience we intend to address into groups who share similar beliefs, attitudes and behavioural patterns. This approach goes beyond the demographic, epidemiological and service uptake databased collection and aims to include data about people’s beliefs, attitudes, understanding and observed behaviours. Target audiences are segmented using these data sets.
Interventions are directly tailored to a specific audience segment rather than being addressed to a broader general audience with the hope that those that need the intervention will be reached (the so-called ‘spray and pray approaches’). In this way we can develop interventions aimed at specific sub-groups and specific behaviours. Audience segmentation also strengthens traditional public health targeting with other data focusing on ‘why people act as they do’ and observing their actual behaviour.
Measles vaccination case (c) – measles vaccination uptake – segmentation of under-vaccinated populations
Studies [22, 23] have identified a range of characteristics of unprotected and under-protected populations (unimmunised and under-immunised populations). In broad terms four key population groups have been identified:
Those who have concerns about perceived safety issues and/or are unsure about needs, procedures and timings for immunising.
Those who consider immunisation a low priority and have no real perceived risk of vaccine-preventable diseases.
‘The poorly reached’
Those who have limited or difficult access to services, related to social exclusion, poverty and, in the case of more integrated and affluent populations, factors related to convenience.
‘The active resisters’
Those with personal, cultural or religious beliefs which discourage or exclude vaccination.
Needs of various key populations
Gathering insights, within representatives of these different groups, raised a variety of concerns related to healthcare providers’ behaviour and communication as well as issues related to messages and system design.
‘Hesitant’ parents noted that healthcare providers’ communication, often due to time constraints, was generally a one-way communication (no patient/doctor dialogue) and the messages were well-intentioned but uniform for all people. Healthcare providers were advised to place more emphasis on dialogues – which first elicit information about parents’ specific concerns and anxieties and then adapt and customise messages to the identified needs of individuals and groups.
‘Unconcerned’ parents asked for healthcare providers to keep the focus of vaccination discussions on the benefits of protection. They indicated their need to be made more aware that when they get their children vaccinated they are protecting them, and the communities in which they live, from serious and potentially deadly diseases.
The ‘poorly reached’ reported a need for improving how services and delivery systems are designed and provided. They asked for more attention to be paid to costs, location, staffing, transport, scheduling and timing as key determinants of vaccination programme uptake and success. They recommended that ‘vaccination journeys ’ need to be made easier.
© European Centre for Disease Prevention and Control, 2014