Not long ago the pop stars Tatiana and Johnny sang and danced their way to the top of musical and video charts in Mexico and Peru with a message for young people about sexual responsibility... In the Philippines, Broadway star Lea Salonga led the charts with her song, "I Still Believe,” on the same topic. And in Uganda, the problem of HIV/AIDS was tackled head-on in a widely distributed comic book, Ekanya: Shocked into Sense. All over the world, popular media contribute to health communication campaigns designed to promote healthy behavior among numerous audiences. They have focused on a variety of public health topics, ranging from child survival and safe motherhood to building healthy and sustainable environments.

Popular entertainment imbedded with a social message is only one of many health communication and education strategies. Many of the basic tenets upon which its success has been predicated have been borrowed from social marketing. This model, launched in the politically aware 1960s with the now-famous question, "Why can't you sell brotherhood like you sell soap?” seeks to promote socially relevant initiatives, behaviors, and ideas using techniques and principles derived from commercial marketers.

For example, social marketing takes seriously the four P's of marketing: product, price, place, and promotion. Each of these factors must be considered carefully in designing a successful social marketing strategy that will respond to consumer needs, desires, perceptions, preferences, and satisfaction.

A product or offering, such as contraceptives or oral rehydration therapy, must be defined and positioned for the target audience on the basis of sound market research. Pricing considerations for these products often involve psychological and social costs to the consumer that are far higher than the monetary costs. In choosing the place where products will be distributed (such as pharmacies and health clinics), a variety of practical considerations must be weighed. For instance, can mothers access a health clinic so that their children can be immunized? Will health personnel be available during nontraditional hours to serve the needs of women and others who have multiple demands on their time during the workday? Will health care providers be kind and courteous, or will they behave in punitive ways that discourage appropriate follow up? Finally, promotion efforts must be culturally sensitive and based on a sound knowledge of relevant limitations.

Let's suppose the product being offered is mammography. What has market research told planners about women's knowledge, attitudes, and practices regarding breast cancer screening and prevention? Specifically, what do women know, think, and believe about mammography? What are their fears and misconceptions? Then, even if screening is free and available, what are the psychological costs to a woman who undergoes mammography? What practical considerations are at play? Will she be embarrassed to have others know where she's been? Is child care an issue? Where will she have to go to be screened? Is it too public a place, or too intimidating? And finally, how will mammography be promoted? What are appropriate message channels, and what are the most salient messages for the intended audience? Who are credible sources of information, and should all levels of fear arousal be avoided? Will paid airtime on radio or television be a worthwhile supplement to public service announcements?

Asking these questions in relation to the four P's of sound marketing help ensure that the designed product is as appealing as possible, that costs are contained, that the positive attributes of the offering are understood, and that there are no barriers in bringing together consumers with services they need. It may also be important to see that the legal and regulatory environment adapts as necessary (broader insurance coverage, in the example of mammography), and to reinforce basic health messages through public relations campaigns aimed at significant others, such as spouses and other partners, as well as health educators.

In addition to the four P's, successful health communication efforts rely on several other principles of social marketing, as well. Audience segmentation—the identification of subgroups for specific messages—is the most crucial of these. A woman's knowledge, attitudes, and beliefs about mammography, for example, will be different from those of her partner or her doctor. Therefore, what is conveyed to a woman about mammography should be different than the message designed to reach her supporters, even though all the messages should be consistent.

The use of integrated mass media is also important. Radio and television can reach millions of people simultaneously, bringing them new information quickly. But the broadcast media alone cannot effect behavior change. Nor can print materials, which serve best as the reinforcement, facilitator, or reminder component. Interpersonal communication usually represents the point of persuasion in deciding to try something new. Both formal and informal communications channels contribute to behavior change.

In the age of high technology, it is also important to remember the role of traditional media in many cultures. Sometimes, nothing is more effective than songs, drama, puppets, and other forms of indigenous folk media for getting the message across in a nonthreatening way.

Finally, qualitative research is central to successful social marketing strategies. A truly client-centered social marketing effort begins with qualitative research conducted by trained personnel working with representatives of the various audience segments to understand and appreciate the distinct mind-set of each group. This kind of research shapes message development and continues to assist planners as they refine messages.

Social marketing today faces some real hurdles. Audiences are sometimes fragmented, thereby making them harder to reach and analyze. At the same time, social products are generally more complex in nature than commercial ones, and frequently they are more controversial and less satisfying to consumers. Audiences, too, often have fewer resources, even though social marketing efforts, like their commercial counterparts, are expected to yield spectacular results. Nonetheless, after decades of social marketing successes, the methodology has proven to be a viable partner in health promotion efforts.

Early social marketing programs contributed significantly to the development of a public health communication model widely used today. That model sees social marketing as a philosophy and a process that is enhanced by several other disciplines. Behavior analysis is able to provide health communication programs with a rigorous focus on the consumer, acting as a microscope to reveal what people actually are doing with regard to a specific health problem, and why. It also takes into account factors in the social environment that influence behavior patterns. By exploring behavioral antecedents and consequences, researchers can explore the rewards and punishments of a particular action.

Anthropology and ethnographic techniques also contribute to the health communication model by providing an understanding of the cultural context in which certain behaviors occur. Every successful public health program needs to consider the prevailing perceptions, beliefs, and values of its intended audience. Through observation, interviews, and other participatory methods of research and evaluation, health communicators can look clearly at the traditions and customs of their audiences and develop compatible programs.

One of the earliest and most successful examples of social marketing for public health comes from Honduras in the early 1980s. Under the auspices of the HEALTHCOM Project, an early child survival communication project sponsored by the U.S. Agency for International Development and carried out by the Academy for Educational Development, significant behavior change occurred among mothers, health workers, and others to reduce the incidence of diarrheal disease in children under 5 years of age. The project worked with the Honduran health ministry to analyze prevalent beliefs about diarrhea and to design and market oral rehydration salts. Health workers and village outreach personnel were trained in the proper administration of rehydration salts and ways to prevent diarrhea. They then taught these practices to mothers. The combined health worker, print, and radio promotion led to a 60 percent trial of a new rehydration salts product among rural women, and over a two-year period, diarrheal-related mortality in children under 5 dropped from 40 to 24 percent in the target area.

Since those early days of public health communication campaigns, the methodology has expanded to include entertainment-education models, media advocacy, indigenous media initiatives, community-based models of problem-solving and materials development, and multimedia campaigns. In South Africa, for example, a television drama series called Soul City was used to impart a number of health education messages. The series, which debuted in 1994, was so successful that it has blossomed into an extraordinary multimedia project that combines prime time TV and radio drama with booklets serialized and then inserted in complete form into newspapers throughout the country. Each year, the series tackles different health and development issues. According to cofounder Dr. Shereen Usdin, a physician and communication specialist in Johannesburg, "the idea has been to capture the attention of prime-time audiences to convey empowering information. We also wanted to create an ongoing vehicle so that we wouldn't have to reinvent the wheel each time we wanted to address an issue. The popularity of the series has ensured this. It also means we begin each series with a massive audience [in place]. To a large extent, what distinguishes Soul City is its emphasis on community activism, which looks beyond a narrow focus on individual behavior to encouraging communities to take control over health issues.” Soul City is now planning to take its methodology into the world of children's broadcasting, with messages designed specifically for 8- to 12-year olds. "There are currently no programs addressing the issues of this age group specifically,” Usdin says. "So this is exciting new terrain. It promises to be a challenge.”

The challenge to reduce maternal mortality in Mali was met by AFRICARE through traditional media. The symbol of le petit pagne vert (the little green loincloth, a kind of lingerie for married women) was used to improve knowledge, attitudes, and practices related to maternal health in rural areas. In this project, nonverbal communication was the focus. Songs and other folk media were developed around the loincloth, which both pregnant women and their husbands wore with pride to demonstrate that they were taking steps to ensure healthy childbearing.

The Pan American Health Organization (PAHO), Regional Office for the Americas of the World Health Organization, works with a variety of partners across Latin America and the Caribbean to develop and evaluate the impact of similar health communication programs. These groups include health ministries; other international organizations; social security health care systems; the mass media; schools of journalism, communication, and public health; university wellness and nursing programs; and health divisions within the armed forces. According to Dr. Gloria Coe, PAHO's Regional Advisor in Health Communication, "our work with both traditional and nontraditional agencies and interest groups enables us to expand the scope of PAHO's health promotion and communication activities and, at the same time, target specific groups—health communicators and educators, physicians, journalists and media gatekeepers, nurses, university students, and armed forces personnel, for example—whose situation places them in a unique position to inform, teach, influence, and guide others.”

The experiences gathered from health communication programs all over the world have confirmed the importance of a systematic approach that combines popular art with medical science. Through a carefully designed strategy that includes assessment, planning, pretesting, delivering, and monitoring of messages aimed at meeting the needs of a given population, health promotion goals can be met.

At the same time, experience has proven to be the forerunner that will enable health communication specialists to face even greater challenges in the future. As the field of health communication grows ever more sophisticated, new and difficult questions about its process continue to emerge. Is individual behavior change as essential as creating an enabling environment for social change? Are large-scale centralized programs more effective than community-based, participatory models? Do mass media approaches obfuscate the benefits of indigenous media and interpersonal contact? Which is better, a private or a public sector approach? How might hybrid models work?

These and other key philosophical and operational questions are being explored by health communication experts and practitioners worldwide. But one thing they all can agree on is that changing social norms is an enormously complex task. Doing so requires both a historical view and a prospective vision. Says Dr. María Teresa Cerqueira, PAHO's Regional Advisor for Health Education and Community Participation: "We know from longstanding evidence in health education programs that a combination of participatory approaches, communication strategies, and educational techniques focused on skills development works best. We also know that health promotion needs to inform public policy initiatives, so that we are promoting aspects of social development as well as healthy behavior.” At the same time, she says, "we need to allow space for indigenous people to develop their own skills and share their knowledge.” The ultimate formula for success, according to Cerqueira, is to develop interdisciplinary partnerships, move beyond competition and turf battles, and learn to negotiate effectively at the political level.