May Kennedy on "Multiple interventions - when and why"

When a program logic model suggests that there are barriers to performing a behavior that would really need to be addressed by different kinds of interventions, then you would launch different kinds of interventions and do the work necessary.  The other reason why you might want to use different kinds of interventions is that a program generally is more effective if the target audience hears a message from a variety of channels.  And so in this circumstance , too, it’s worthwhile, to launch a variety of interventions.

There are some very interesting case studies that are examples of the use of social marketing in which a variety of different kinds of interventions were employed.  If you go to http://www.turningpointprogram.org, you’ll see a document called “Lessons from the Field” and there are descriptions of quite a few cases that are of this sort.

One that I recall offhand is a program in which the concern was obesity among Hispanic children and the identified problem was that mothers were not feeding skim milk to the children; they were feeding whole milk to the children. There were important misconceptions…they felt that the skim milk had been watered down and that needed to be debunked with  a communication campaign.  But there was also a barrier because the bodega grocery stores didn’t carry skim milk, so the policy of the bodegas had to be changed and the misconception had to be debunked through a communication campaign.  The way this all worked together, including incentives that children got for turning in the box tops from the skim milk at school, all integrated together into a coherent campaign, is described in one of these case studies and there others like that.  There are also text books, like one by Kotler and Andreasen, that describe programs that have multiple components all woven together.

When you launch a program that has a number of intervention elements, there are tremendous logistical challenges.  Each one has to be pilot-tested prior to launch.  Each one has to be managed and monitored for quality control throughout and this is very demanding.   Just the mechanics involved in a communication campaign where you test concepts and you test execution and you work with creatives to get perhaps a poster or PSA is demanding enough.  When you combine that with working with say groups of providers to change the way a service is delivered, you can see that the complexities multiply geometrically and it becomes very complicated.  However, having his marketing mix of integrated components that makes a behavior not only something that people think of and understand the importance of, but also find easy to do is worthwhile and can really help you reach your program goal.

There are a lot of political challenges when it comes to employing a variety of intervention strategies.  One of the political challenges is that often you have to work through coalitions to achieve political goal, policy goals and you can’t always predict the outcome of coalition deliberations.  Coalitions do things more slowly than individuals do who can make executive decisions and act on them.  Vetting proposals through multiple layers of organizations is not only slow but also unpredictable in term of its timeframe.  Often different members of a coalition will have very different ideas about whether a problem should be approached with an upstream sort of policy intervention or a downstream service or product or communication intervention, and there can be a lot of heated debate. So its important to realize that when you go beyond something that you have complete control over, things are slower and more complicated . The way though that a lot of these conflicts are resolved is that we go back to the audience research and if you can tie very clearly what you are proposing to what the audience has told you in focus groups or similar types of formative research, often the coalition members will often come around to some unified  point of view.

It is very difficult to evaluate a program that involves a number of different kinds of intervention elements…the basic strategy for evaluating a large-scale, community-wide intervention or national campaign is to associate exposure to your campaign with levels of your desired outcome. When you’ve got a variety of different kinds of programs, you have to decide what counts as exposure and that can be difficult, particularly if you expect one of your of your levels of intervention to impact others.  Say you want to intervene at the policy level and also communicate directly to a target audience, but the audience is influenced not only by your communication but also indirectly, through policy makers.  Who do you interview, what do you count , what kinds of statistics do you use?  This is a multi-level statistical model. Teasing out the memory of exposure to one intervention versus another is problematic.  People have a really hard time remembering exactly what they’ve been exposed to, exactly where they got the message.  So in a lot of cases, evaluators don’t really try to isolate the effects of each individual component intervention in an integrated program -- it’s really hard to do.   You can do some interviews with people and get a general sense for what they remember being exposed to, but it’s very hard to do with a high degree of reliability.

Generally speaking, there is a correlation between the number of intervention components you would launch and the amount of resources required to launch that program.  However, there are low cost strategies that can be employed for service tweaking, for communication elements, and so on. You may be able to partner with an existing coalition and reach a policy goal and then you don’t have to do the organizing.  You may be able to change a name or label on an existing product and not go all the way back to the lab.  You might be able to change service hours to make them more convenient and not provide completely new services. There are low cost strategies, but in general, multiple programs are going to require more resources.