social marketing in action—geodemographics, alcoholic liver disease and heavy episodic drinking in...

International Journal of Nonprofit and Voluntary Sector MarketingInt. J. Nonprofit Volunt. Sect. Mark. 12: 177–187 (2007)Published online 27 June 2007 in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/nvsm.309
Social marketing in action—geodemographics, alcoholic liverdisease and heavy episodic drinkingin Great BritainJane Powell1*, Alan Tapp2 and Emily Sparks3

1Faculty of Health and Social Care, University of the West of England, Bristol UK

2Business School, University of the West of England, Bristol, UK

3Experian Nottingham, UK

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*CorSociaE-ma

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his paper explores the use of geodemographic population classifications to identify and

predict ‘hotspots’ of Great Britain (England, Scotland and Wales) prone to greater than

expected alcoholic liver disease. MOSAIC geodemographic codes were overlaid onto

Hospital Episode Statistics (HES) for Great Britain. The HES data included gender,

MOSAIC Type, MOSAIC Code, postal and local authority district, month and year of

birth, ethnic origin, Primary Care Trust and GP code. Analysis demonstrated that some

geodemographic classifications of the populationwere over-represented for alcoholic liver

disease episodes. These groups had low socio-economic and socio-cultural status, lived in

areas of high deprivation and disadvantage. Manchester followed by Liverpool and Hull

had the highest estimated patient group size in England and Hart, Surrey Heath and

Wokingham the three lowest (indicating low expected levels of alcoholic liver disease

compared with average). Analysis of the same data was also carried out at postcode level

for Manchester indicating ‘hotspots’ for alcoholic level disease at street level. This analysis

exemplifies the ways in which geodemographic data might be usefully applied to routine

health service data to enhance service planning, delivery and improved targeting of

information in harder to reach populations.

Copyright # 2007 John Wiley & Sons, Ltd.

Introduction

There are mounting concerns about the socialand personal effects of alcohol misuse in theUK (Great Britain and Northern Ireland). Percapita alcohol consumption in the UK rosefrom 7.6 to 8.2 litres (of pure alcohol perannum) between 1990 and 2002, a rise of 8 per

respondence to: Jane Powell, Faculty of Health andl Care, University of the West of England, UK.il: [email protected]

yright # 2007 John Wiley & Sons, Ltd. I

cent (Plant and Plant, 2006). It is true that percapita alcohol consumption in the UK remainsin the mid range by European standards, butnevertheless it is at its highest level since 1914and is still climbing. Particular concerns haverecently been expressed at the pattern of‘heavy episodic drinking’ (defined as morethan 5 drinks at one 2 hour drinking occasionfor a male and more than 4 in a row for afemale) in the UK and other Northern Europeancountries (Plant and Plant, 2006). It typically

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178 Jane Powell et al.

takes between 5 and 10 years of very heavydrinking to cause liver cirrhosis (Gilmore,2007). Liver failure can result from continuingto drink alcohol once pre cirrhosis fatty liverhas been diagnosed (Gilmore, 2007). Inparticular the levels of heavy episodic drinkingin the UK have long been amongst the highestin the world.

Both heavy episodic drinking and chronicheavy drinking or alcohol misuse have bothbeen linked to a variety of negative health andsocial consequences in the UK and elsewhere(Powell et al., 2006). These include alcoholicliver disease, anti social behaviour, violence,crime levels and time off work. Incidence ofalcoholic liver disease has increased over thelast 5 years, especially in the age group under30 years (Plant and Plant, 2006). Post devolu-tion governments in England, Scotland andWales have attempted to respond with avariety of initiatives. For example, in Englandthe Alcohol Harm Reduction Strategy forEngland (AHRSE) (Cabinet Office, Prime Mini-ster’s Strategy Unit, 2004) outlined the wide-spread lack of knowledge of sensible drinkinglimits within the population and the need toaddress this shortfall. The White Paper ‘Choos-ing Health—Making Healthy Choices Easier’(DH, 2004) called on marketers for help to turngood health into an ‘aspirational commodity’.The use of this expression suggests thatpresumably at least one government is think-ing of deploying ‘social marketing’ in theinterests of good health. Indeed, health pro-fessionals and academics are increasinglyinterested in ‘social marketing’ as a way oftackling health problems that are considered‘preventative’ (National Social MarketingCentre for Excellence, 2005). The linkbetween health and social marketing is com-plex and multi-levelled, but in England therehas been work establishing a theoreticaldimension to marketing as a positive forcefor better health via the social marketingparadigm (National Social Marketing Centrefor Excellence, 2005). This work in socialmarketing was mentioned in the influentialsecond Wanless review of UK health spending(Wanless, 2004).

Copyright # 2007 John Wiley & Sons, Ltd. In

Government in Great Britain has identifiedthe desire to encourage so called ‘Europeancafe society’ drinking habits, that is, moderatelevels of drinking over a longer time period in amore relaxed manner. Lefebvre and Flora(1988) propose the key components of socialmarketing as consumer orientation, identifi-cation of key audiences through segmentationand analysis, voluntary and mutually beneficialexchange, formative research, clear objectivesetting, channel analysis, a marketing mix ofproduct, place, promotion and monitoringevaluation. In particular, as these authors pointout, marketers are keen to influence consumerbehaviour. Social marketing could have a rolein influencing people to adopt more desirableand healthier ‘cafe society’ drinking patternsand habits rather than heavy episodic drinkingby emphasising the hidden and misunderstoodharms.

In this paper we are primarily concernedwith the idea of market segmentation as a wayof identifying and targeting heavy episodicdrinkers more accurately as a precursor tosocial marketing programmes for behaviouralchange. Segmentation based on a range ofattributes is central to effective social market-ing (Naidoo and Willis, 2006; Wanless, 2004).Indeed, while the language of public healthdiscourse may not express it in these terms, theidea of market segmentation is now increas-ingly commonplace in health policy (Ormeet al., 2007). In particular, there is a realisationthat achievement of the Wanless ‘fully engagedscenario’ depends crucially upon the engage-ment of ‘deprived and marginalised’ commu-nities in their own health; if it is to besuccessful (Wanless, 2004).

Some sections of the population experiencebarriers that thwart and prevent attempts tolive healthy lifestyles because circumstancesand context are not conducive to healthimprovement. The White Paper ‘ChoosingHealth—Making Healthy Choices Easier’recognised that people need supportiveenvironments within which to change beha-viour, but some people also needed individu-ally tailored health improvement plans (DH,2004). In addition, ‘Choosing Health’ argued

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Social marketing in action 179

the importance of understanding context in anindividual’s healthy lifestyle, acknowledgingthat this includes a whole host of socio-economic and socio-cultural factors, as wellas peoples’ own attitudes and beliefs surround-ing good health.

Alcoholic liver disease—bringingtogether public health preventionpolicy and social marketing inGreat Britain

There is recognition that making healthychoices is easier for some people than othersand in the case of heavy episodic drinking, wecan begin by examining socio-environmentalfactors and their impact on poor drinkingbehaviours. A complex multi-layered environ-ment is revealed with three groups of factorscontributing to the increased drinking levelsidentified. These are: First, the presence of ‘atrisk’ groups in terms of medical and socio-economic factors. Second, the presence ofconditions likely to contribute to heavydrinking levels, for example, poverty andsocial marginalisation. Finally, the presenceof psychological or environmental risk factors,for example, lack of social support, exposureto alcohol drink advertising and poor access tohealthier alternatives (Dorsett and Dickerson,2004; Nayga, 1999).

If, as current health policy identifies, socialmarketing is an important approach in futurebehavioural change strategies, then it is vitalthat market segmentation and targeting areeffected as precisely as possible. This may meansegmentation that is achieved using a largenumber of relevant ‘patient’ characteristics.

The central purpose of this paper is toexamine the case for linking a segmentationdatabase of the UK population (MOSAIC UK)with health services data (Hospital EpisodeStatistics (HES) for Great Britain) to givedirection to post devolution public healthpolicy on alcoholic liver disease linked to heavyepisodic drinking in Great Britain in a targetedand appropriate way. From a health marketingperspective, this gives public policy makers andhealth professionals in England, Scotland and

Copyright # 2007 John Wiley & Sons, Ltd. I

Wales a platform for ‘understanding the con-sumer’ and a practical targeting tool from whicha social marketing strategy can be designed.Hence in this paper we combine commerciallysourced geodemographic data for Great Britainwith HES data for alcoholic liver disease inEngland in 2001–2002 to generate detailedgeodemographic profiles of population groupsat national, city, town, ward and street levels.Geodemographic data can be applied to under-stand the context in which tailored behaviouralinterventions could be designed and how andwhere resources might be targeted to deliverbehaviour change with social marketing initiat-ives. At the present time, geodemographicprofiling combined with routine NHS data hasnot been used in a predictive manner to identify‘liver disease-hotspots’ at various levels ofpopulation aggregation.

Research design and methods

A predictive, secondary data analysis was runusing HES of alcoholic liver disease for2001–2002 with 61 appended geodemographicMOSAIC Group and Type codes for GreatBritain at local authority and postal district level.An index was created for each MOSAIC Type,with 100 equalling the national average.

Hospital episode statistics for alcoholic

liver disease

This dataset contains entries for 12.8 millionovernight hospital admissions to all hospitals inGreat Britain in 2001–2002. Each data recordfor admissions contains a diagnostic codeindicating the health problem that necessitatedan overnight stay in hospital. Alcoholic liverdisease has its own separate code. HES alsorecord patient date of birth, ethnicity, PrimaryCare Trust code, GP code, local authority codeand postal district code.

MOSAIC geodemographic

classifications for all households

MOSAIC UK is a commercial dataset owned byExperian Ltd. It is a way of grouping together


DOI: 10.1002/nvsm


households into clusters described accordingto their geographic and demographic charac-teristics. MOSAIC is based on Census data,collected by the Government for all UKHouseholds every 10 years. It is built in fourstages: a detailed analysis of social trends in theUK, identification of the most appropriate datasources as inputs, a sophisticated approach toclustering methods and extensive fieldworkand market research to assist in validation andinterpretation of the segmentation. A total of400 variables are used to build MOSAICprofiles and these are updated annually. Fiftyfour per cent of the data used to build MOSAICis sourced from the 2001 Census. The remain-ing 46 per cent is derived from a consumersegmentation database, which provides cover-age of all of the UK’s 46 million adult residentsand 23 million households using the ElectoralRoll, lifestyle survey information, consumercredit activity, post office address file, Share-holder’s Register, house price and council taxinformation and ONS local area statistics.MOSAIC classifies consumers by household

Figure 1. Incidence of alcoholic liver disease in Englaninterscience.wiley.com/journal/nvsm


or by postcode which allows optimisation ofuse of the segmentation depending on appli-cation. In the analysis that follows the data forNorthern Ireland were not included.

HES for alcoholic liver disease wereappended to 61 Mosaic Types from theMOSAIC UK geodemographic dataset. EachMOSAIC Type is part of a bigger cluster of 11MOSAIC Groups denoted by letters A–K. EachMOSAIC Group and Type has a name. For eachType, a national average incidence of alcoholicliver disease would receive an index of 100, soany index over 100 highlights an area with agreater than average incidence of alcoholicliver disease and hence a possible target forsocial marketing.

Results

HES for alcoholic liver disease were matchedagainst geodemographic codes for the popu-lation of Great Britain. In this paper we reporton these figures aggregated for Great Britain.Figures 1–4 illustrate the results. Figure 1

d. This figure is available in colour online at www.


DOI: 10.1002/nvsm

Figure 2. Mosaic Types profile of alcoholic liver disease. This figure is available in colour online at www.interscience.wiley.com/journal/nvsm


illustrates the incidence of liver disease inEngland clearly demonstrating its unevengeographic incidence. This uneven spreadwhich occurs across Great Britain (not shown)is conducive to possible segmentation.

Figure 2 demonstrates that the highestincidences of alcoholic liver disease areMOSAIC Types ‘Tower Block Living’, ‘Digni-fied Dependency’ and ‘Upper Floor Families’,


all part of the MOSAIC Group ‘WelfareBorderline’. These titles for each cluster groupor type attempt to describe the people therein,using deliberately colourful language. ‘WelfareBorderline’ areas comprise people who live inconsiderable social disadvantage, often inpoor conditions in the tower block flats ofinner cities. Residents in welfare borderlinegroups struggle to achieve the personal and


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Figure 2. (Continued).


economic rewards that better off people takefor granted.

Not surprisingly MOSAIC Types within group‘G’, ‘Municipal Dependency’, also score highlyon alcoholic liver disease. ‘Low Horizons’,‘Families on benefits’ and ‘ex-Industrial Legacy’are all around twice as likely as the nationalaverage to contain incidence of alcoholic liverdisease that required hospitalisation over night.Once more, the names of the Group and Typesattempt to describe the data analysis profiles ofthe inhabitants. Municipal Dependency areasare characterised by large, low rise councilestates on the edge of large cities. People livinghere often feel cut off from much of mainstream(consumer) society. They are demographicallysimilar to Welfare Borderline groups in theMOSAIC classification, being less well off,poorly educated and much more likely tocomprise social grades D and E than average.

One surprise from this set of data is theextremely low index for Type 40 ‘Sharing aStaircase’, part of the ‘Welfare Borderline’group. ‘Sharing a Staircase’ people share many


of the demographics of Welfare Borderline:less well off, working class and poorlyeducated people who live in deprived areas.However, ‘Sharing a Staircase’ has people whoare younger, much more likely to be singleparents (index of 320) and much more likely tobe unemployed (index of 250 for social gradeE). Long term health is on average also verypoor. Having a family is a protective factor forheavy episodic drinking. In addition, incomesmay be too low to support heavy episodicdrinking, or priorities for such non-nuclearfamilies with young parents may be morefocused on daily survival than drinking forenjoyment.

People within Group ‘D’, in particular Types‘Town Centre Refuge’ and ‘Coronation Street’,have more than twice the national averageincidence of alcoholic liver disease. Group ‘D’,called ‘Ties of Community’, typically com-prises working class towns in manufacturingstrongholds within the country, many of thesenow in decline as the industries upon whichthey depended have moved elsewhere in the


DOI: 10.1002/nvsm

Figure 3. Geodemographic predictors of heavy drinking.


world. However, within this group are Typeswith distinctly different incidence of alcoholicliver disease. ‘Industrial Grit’ (former miningcommunities) for example has only averageincidence, much lower than ‘Town CentreRefuge’ (typically young unattached people insmall flats, maybe above shops in high streets)or ‘Coronation Street’ (less well off people insmall terrace houses close to the centre ofprovincial cities). It may be that the socialcohesion of ‘Industrial Grit’ differentiatesotherwise similar socially positioned peopleand explains the lower index.

Residents of Group I ‘Twilight Subsistence’have indices around the 150 mark. MOSAICTypes within this group with high indices are‘Cared for Pensioners’, ‘Old People in Flats’and ‘Low Income Elderly’. Clearly these groupsare characterised by elderly people on rela-tively low incomes. People who live in areas

Figure 4. Anticipated inputs into a social marketing camp


characterised as ‘Twilight Subsistence’ have ahigh average age, and a lower than averageincome. They may not be well educated, andwill typically have lower social class back-grounds. These people may not be particularlymobile and are likely to have low aspirationswith the remainder of their lives. The MOSAIC‘J’ group, ‘Grey Perspectives’, though of similaradvanced years, will be better off and bettereducated than the ‘Twilight Subsistence’group, and it is interesting to note the dramaticdrop in liver disease that occurs in the J Typessuch as ‘Bungalow Retirement’. A glance at thelow indices for Types within MOSAIC GroupsA, B and C highlights the low incidence of liverdisease amongst well off, middle class and welleducated people. However, social class, edu-cation and income do not always explain thedata. If we examine Type K59—‘ParochialVillagers—it is worth highlighting that these

aign to reduce heavy episodic drinking.


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Table 1. Demonstration of geodemographics as atargeting system: illustrative ranking list of conurbationsby alcoholic liver disease index

EMS index

Manchester 180.35Liverpool 169.46Kingston upon Hull, City of 167.72Nottingham 160.27South Tyneside 158.83Knowsley 157.81Middlesbrough 154.44Salford 153.64Gateshead 151.09Newcastle upon Tyne 148.75


are predominantly working class areas (socialgrade C2 is higher than average), but with aliver disease index of only 54—around half thenational average. Here too, social cohesionmay play a part in reducing adverse healthbehaviours.

Tables 1 and 2 illustrate the power of theanalysis in drilling down into smaller geo-graphic areas while increasing the incidence ofalcoholic liver disease. These tables highlightthe practicality of the data in allowing socialmarketers to target messages almost to anindividual level.

Hartlepool 148.61Sunderland 144.86Dundee City 144.04Leicester 143.94Stoke-on-Trent 143.29Lincoln 142.55Merthyr Tydfil 142.24Norwich 139.38Easington 139.37Sandwell 138.85Birmingham 138.70Hackney 137.52Blaenau Gwent 137.46Rochdale 137.33Wolverhampton 137.00Halton 136.11Blackpool 134.82Blackburn with Darwen 134.78Tower Hamlets 134.20Burnley 133.40Corby 133.29Sevenoaks 63.07Mid Bedfordshire 62.75West Oxfordshire 62.44Fareham 62.00Richmondshire 61.88Vale of White Horse 61.76West Berkshire 61.66Rutland 61.57Horsham 61.28East Hertfordshire 61.11Harborough 60.96Guildford 60.55Windsor and Maidenhead 60.01Mid Sussex 59.15Mole Valley 58.81South Oxfordshire 58.34Uttlesford 58.34Epsom and Ewell 58.26East Dorset 57.81Waverley 57.75South Northamptonshire 57.71South Cambridgeshire 57.64St. Albans 57.27

(Continues)

Academic implications

Figure 3 summarises the key geodemographicvariables that predict alcoholic liver diseaseand heavy episodic drinking.

As Elliot et al. (1994) point out, there isnothing new about the use of social marketingtechniques to try and reduce heavy episodicdrinking. The World Health Organisationinitiated a review in 1979, and early collabora-tive international projects were completed bythe early 1990s. ‘Brief interventions’, involvinga 5 minute interview, proved of some use, butthere were difficulties, not least with GP’s takeup of the approach. Elliot et al. (1994)reported on a more rounded social marketingprogramme ‘Drink Less’, including GP focusgroups and easily administered packages ofinformation for patients. Nonprofit motiveshelped secure high credibility, while the ‘push’nature of the campaign was felt to be moreeffective than a patient ‘pull’ approach via‘social advertising’. However, it was less clearprecisely what the keys to persuasion werefrom this work. Darian (1993) studied under-graduate drinking at a US campus, and onetrigger for lower drinking was felt to be anemphasis on personal susceptibility to nega-tive consequences. However, the UK datareported here clearly show lower social classand low income groups are, on average, inmuch more danger of alcoholic liver diseasethan college students who face a relativelymuch brighter future.

Copyright # 2007 John Wiley & Sons, Ltd. Int. J. Nonprofit Volunt. Sect. Mark., August 2007

DOI: 10.1002/nvsm

Table 1. (Continued)

EMS index

Richmond upon Thames 56.84Tandridge 56.36Elmbridge 55.10Chiltern 53.95South Bucks 52.79Wokingham 50.83Surrey Heath 50.76Hart 47.60


Advertising specialists (Curtis, 2004) cite thesuccess of ‘Tobacco Control’ and ‘Think!’(driving speed) campaigns as evidence thatadvertising is an effective social marketing tool.However, a closer look suggests these cam-paigns used a ‘multiple partner approach’ and

Table 2. Manchester district drilled down for more powe

M 4 5 Swan Street, ManchesterM 40 7 Miles Platting, ManchesterM 4 7 Ancoats, ManchesterM 4 6 Beatson Walk, ManchesterM 9 5 Harpurhey, ManchesterM 40 8 Alburn Ct, Lifton Avenue, ManchesterM 15 4 St George’s, ManchesterM 22 9 Mottershead Road, ManchesterM 40 2 Newton Heath, ManchesterM 11 3 Bradford, ManchesterM 12 6 Ardwick, ManchesterM 11 2 Openshaw, ManchesterM 22 8 Greenwood Road, ManchesterM 12 5 Newsholme Walk, ManchesterM 13 9 Plymouth Grove, ManchesterM 11 4 Clayton, ManchesterM 18 7 Buckley Road, ManchesterM 22 1 Saintsbridge Road, ManchesterM 11 1 Trevor Street, ManchesterM 14 7 Auster Close, ManchesterM 14 4 Moss Lane Evens, ManchesterM 22 0 Wythenshawe, ManchesterM 23 2 Rowarth Road, ManchesterM 21 7 Woodlake Avenue, ManchesterM 9 6 Dam Head Drive, ManchesterM 9 7 Cartmel Court, ManchesterM 12 4 Stanley Grove, ManchesterM 18 8 Gorton, ManchesterM 20 1 Meltham Avenue, ManchesterM 16 7 Moss Side, ManchesterM 9 4 Margaret Ashton Close, Manchester


united stakeholders ‘around a common themeor brand’, hence pointing to a moreco-ordinated approach to health campaignsin future. We suggest that this is the approachrequired given the problems anticipated inreducing heavy episodic drinking amongsttarget audiences, as illustrated in Figure 4.

As Pitcher (2004) indicates, the low selfesteem and lack of desire to progress on ‘sinkestates’ requires a wholly different socialmarketing approach to that aimed at reducingheavy episodic drinking amongst more for-tunate groups. These are difficult socialproblems to solve. To add to the social issues,Hastings and Saren (2003) point out that socialmarketing does not exist in a vacuum: a greatdeal of commercial marketing encouragesbeverage alcohol drinking, and any socialmarketing must take account of this. Marketing

rful targeting

EMS index Base count

318.59 592309.61 6203306.50 1370298.56 1347296.37 4033294.53 3718274.84 4064272.30 7910270.14 5238269.84 3748268.18 1193264.54 2785261.29 4436253.18 6976250.82 5631239.26 7908238.00 10 986235.07 7057234.60 6110227.47 11 082223.67 7989222.99 3634221.95 5714221.82 6663220.83 8605220.03 5321218.13 6325217.40 10 131213.47 7266212.73 5854212.65 8080


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as a negative force on society has beenhighlighted with recent concerns about theuse of promotions and on site marketing thatencourages heavy episodic drinking, particu-larly among young women and young people.However, the data reported here underlinethat the recent focus on young, teenage groupdrinking behaviour may lead to long termheavy episodic drinking and alcoholic liverdisease. For instance, students may well(binge) drink heavily, but for many this is alife-stage they will pass through, settling downand drinking less as they mature. These groupsare distinct and arguably less of an issue forsociety than chronic heavy drinkers or heavyepisodic drinkers of 10 plus years duration.

Conclusion

The data reported here suggest that the heartof the problem lies in the low quality of life andsocial deprivation experienced by the poorestin society for whom there are few prospectsfor improvement, and for whom short termfixes in the shape of heavy episodic drinkingoffer temporary escape. Any social marketingthat does not recognise these realities is likelyto fail. The core principle of social marketing isto begin by understanding the consumer via anexchange of information, and then use this toenhance quality of life. The suggestion here isthat geodemographic analysis allows us toclearly identify, understand and then closelytarget those groups most vulnerable to heavyepisodic drinking and chronic heavy drinkingleading to alcoholic liver disease with pro-grammes that reflect a deep understanding ofthe life of the recipient.

The data reported here suggest that thetheoretical and practical benefits of thecombination of NHS data and geodemographicprofiling are considerable. Health professionalsand public health policymakers could use theapproach outlined in this paper to devisetailored behavioural interventions includingsocial marketing to various segments of thepopulation at country, city, towns, ward,neighbourhood and street levels. Changing


one’s life to overcome heavy episodic drinkingis very difficult. There are clearly big social,cultural and psychological barriers to over-come. The first premise of social marketing isthat these barriers must be understood beforeattempting to influence change. From apractical standpoint, geodemographic toolsallow precise targeting of particularly vulner-able groups, which means resources can beprecisely deployed to areas of most need.

Acknowledgements

The authors would like to thank Experian Ltdfor their permission to use the data on whichthis paper is based.

Biographical notes

Jane Powell BSc, MSc, PhD is a Senior Lecturerin Health Economics and Programme Leaderfor the MSc in Public Health at the University ofthe West of England, Bristol, UK.Alan Tapp BSc, PhD is a Professor of theMarketing Research Unit and Director of Mar-keting at the University of the West of England,Bristol, UK.Emily Sparks BSc, MSc works for Experian,Nottingham, UK.

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