Welcome to the lesson “Statement of the problem” of course 2 of the social marketing
Management Program for Public Health
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SEM
If we want to achieve behavior change for the public good, we first need to have a crystal-clear
definition of what is the problem we are trying to solve.
That’s exactly what we will cover in this lesson: the formulation of the problem using the social-
ecological model of health, also called SEM, as a framework.
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By the end of the lesson, you should be able to describe how a public health issue is identified,
describe the issue and general purpose of your program, and formulate a statement of the problem
you want to address using social marketing.
Please note that in this lesson we are not discussing a specific behavior, but rather the bigger
picture health problem that is associated with that behavior
This step will allow us to identify a specific behavior we want to change or initiate, which we'll see
in the next lesson.
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We can think of a health problem as the gap between the current state of things and a desired
outcome or situation.
What is currently happening? To pinpoint a problem, we need to describe the current situation and
highlight how it differs from what we consider desirable or acceptable.
And, what is likely to happen if we don’t address this problem. Any negative consequence? Missed
opportunity?
It is also helpful to answer these questions to have a better idea of the problem.
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As a second step, we need to describe who is being affected by the problem: is it mostly men?
Women? Children? Old people? Of which age? Where?
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A way to identify problems in public health is to look at epidemiological data and analyze what is
data telling us.
As an example, the graph shows the number of measles cases by year in the USA. The increasing
trend shows that something is happening that needs to be addressed, as the number of cases in
2019 was much higher than in previous years.
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If we dig into the data, we find that New York has been one of the states experiencing outbreaks of
measles since 2018. Among the most affected communities is the one of Williamsburg in Brooklyn,
New York City.
Cases occurred primarily among unvaccinated people in Orthodox Jewish communities and these
outbreaks were associated with travelers who brought measles back from Israel, where a large
outbreak was occurring.
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As an additional example, during the COVID-19 pandemic the NYC Department of Health has
released data on the number of cases by neighborhood in New York City. These data can help
identify the geographical spread and subsequent needs of the different communities in the city.
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Once we identified the problem, we can use health status indicators to aid our reasoning around
the need to intervene. Examples of indicators include death rate, the incidence or prevalence of
certain diseases such as the number of cases of measles, number of injuries, access to services
indicators, such as screenings received, or health-related events such as unintended pregnancies.
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Now it’s time to describe the problem in as much detail as possible. This means identifying how
different actors and factors interact with each other, as well as the sources of information,
stakeholders and other interventions that are addressing the same larger problem.
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For example, you might look to reports that may have been published by the Ministry of Health or
international health organizations related to the public health problem.
Or you may look up research studies in journals to see how the problem has been addressed and
what gaps remain.
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A framework we'll use to describe a public health issue is the Social-Ecological Model of health.
Why socio-ecological?
Historically, socio-ecological models have been used in social sciences to explore how individuals
and the external environment interact and affect human development. Its strengths derive from the
fact that this model focuses on the nature of people’s interactions with their environments, rather
than analyzing individual behavior alone or focusing on just one factor of influence at a time.
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Social-ecological models of human behavior have evolved over a number of decades in the fields of
sociology, psychology, education, and health. Applied to health, this framework considers how what
is true for individual health is also true for population health – in that you cannot look at individual-
level issues without thinking about or examining the larger context within which they occur.
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The SEM typically identifies 5 levels.
Click on every one of them to see what they mean:
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If we look at the 4 core principles of SEM, we find that it points out that
1. health issues result from a combination of factors
2. The influences interact across levels
3. Multilevel interventions should be more effective in changing behaviors, and
4. Ecological models are more powerful when they are behavior specific
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Focusing on a specific behavior rather than a broad health issue helps study the factors and
environments that contribute to the problem more effectively.
For instance, instead of analyzing the issue of childhood obesity broadly, one could use the SEM to
zero in on why children eat unhealthy snacks.
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This prompts questions that are specific and measurable, and can, therefore, be more easily
answered by research: for instance,
which factors at the individual level contribute to this behavior (e.g. taste)?
At an organizational level, for example, are supermarkets marketing unhealthy items to children?
At a policy level, what are the regulations for the advertisement of these products?
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We can use an example drawn from the literature on the H1N1 influenza vaccine uptake.
As you are likely aware, the flu (influenza) can cause mild to severe illness, and at times can lead to
death. The flu vaccination has shown to reduce the risk of flu-associated hospitalization for children,
younger adults, and older adults.
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The figure shows that there are factors that influence the vaccination rates at all levels of the SEM.
For instance at the policy level, issues related to health insurance policy and whether or not the
government has identified a group of people with higher priority access to the vaccine (e.g. elderly)
are factors that influence the uptake.
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At the community level, whether cases of the disease have been found in the community will
influence people’s decision to be vaccinated. For that to happen though, vaccination services have
to be available and accessible in local hospitals (institutional or organizational level).
One’s social connections and the actions and opinions of family and friends can also impact the
vaccine uptake.
At the intrapersonal level, perceived risk, attitudes and trust are among the factors that play a role
in shaping the magnitude and characteristics of the problem.
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As you can see, this example shows how the use of the SEM unpacks a public health problem and
identify the factors that contribute to why the population may not be engaging in the behavior that
you are advocating for. Keep in mind, when we say factors, these are more likely related to barriers
that one faces and at times could be benefits as well.
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This example shows the SEM applied to the issue of colorectal cancer screening. This graph from
the Centers for Disease Control and Prevention (CDC) shows a multi-level approach to prevention to
understand which factors or actors can help increase the uptake for screening services.
Developing something like this can help you to categorize information you have learned about from
reviewing the literature, program reports or personal experiences. Based on this information you
can establish the broader purpose or focus of your social marketing intervention.
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For example, a focus could be increasing measles vaccine coverage rates in the neighborhoods
affected by the measles outbreaks. You will learn more about defining the specific behavior that
your program will target in the next lessons.
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All the elements that we have discussed go into the statement of the problem. This is also
sometimes called “challenge statement”, which has a more positive connotation to it as it frames
the issue as something positive that we need to build rather than a problem to solve. Our statement
is informed by secondary data available and our own experience in previous projects.
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The statement should overall cover the following questions. What is the issue at hand? Who is
affected (now or in the future)? What is likely to happen if no action is taken? What do we know?
Which factors, stakeholders, sources of information, help address the larger issue?
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In this program, we are focusing on public health topics. However, these considerations on the
statement of the problem apply also to social issues such as environmental conservation. For the
sake of illustrating how to write a statement, let’s see an example on biodiversity conservation in
the Caribbean. We will then review a public health example.
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St Lucia parrot, a brilliantly colorful bird native of the island, was at the edge of extinction in the
70s.
Factors contributing to the problem were that the national legislation to protect the species was
outdated (going back to the 19th century) and that the fine for killing the parrot was only a few
dollar). There were no sanctuary or facilities aimed at protecting the parrots. It was socially
acceptable to hunt, eat or keep the parrots caged as pets.
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Now, read the statement again and click on the icons to find how it can help us to answer the
questions around the problem
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Here you can read another example of statement of the problem. In the previous course, we
presented a case study on the VERB Summer Scorecard, a program implemented in the state of
Kentucky in the USA to encourage young residents to be physically active.
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2004
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Here you can see how the statement contains the main information, including what is the key issue, who is affected by the
problem, the public health relevance of the issue and possible factors contributing to it.
Of course, there are several factors that can contribute of childhood obesity, many of which are not at the individual level,
but rather depend on the policies around healthy food availability and affordability.
In this case, the project focused on addressing physical activity which is an individual behavior that is influenced by a variate
of contextual variables such as the ones highlighted in the statement
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In summary, in this lesson we have discussed how to focus on a public health problem using the
social-ecological model of health. You should now be able to identify a problem that you are
interested in addressing, describe the different levels of factors that affect it and formulate a
statement.
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