Strokovni čl an ek Javno zdravje 2018; 2(2): 9-13 www.nijz.si/revijajavnozdravje 10.26318/JZ-03-02 9 Abstract Digital marketing is an important and challenging determinant of exposure to risk factors of noncommunicable diseases. Children are especially vulnerable, because they are using digital platforms widely and increasingly, while they (and their parents) may be unaware of the ethically controversial techniques of digital marketing being used on them and/or may be unable to resist them. National institute of public health of Slovenia together with WHO Country office in Slovenia launched digital marketing initiative and organized capacity-building workshops in 2016 and 2017 to provide cross-sectional analysis of the digital marketing communication to children in three European countries, link public health silos and create joint recommendations to tackle this area. The needs for further elaboration of ethical issues, all types of capacities, development of close monitoring and effective regulation of digital marketing to children were identified. Key words digital marketing, children, public health silos Izv leč ek Digitalni marketing predstavlja izziv in hkrati tudi pomembno determinanto izpostavljenosti dejavnikom tveganja na področju nenalezljivih bolezni. Otroci so še posebej ranljivi, saj je uporaba digitalnih platform med njimi že zelo razširjena in še narašča; medtem ko se tako otroci kot njihovi starši morebiti ne zavedajo etično spornih tehnik digitalnega marketinga, ki se na njih uporabljajo in/ali se jim ne morejo upreti. Nacionalni inštitut za javno zdravje Slovenije je skupaj z Uradom Svetovne zdravstvene organizacije v Sloveniji sprožil podbudo na področju digitalnega marketinga ter v letih 2016 in 2017 organiziral delavnice za krepitev zmogljivosti z namenom izvedbe presečne analize digitalnega marketinškega komuniciranjaotrokom v treh evropskih državah, povezovanja javnozdravstvenih silosov in oblikovanja skupnih priporočil za rešitve na omenjenem področju. Izsledki kažejo na potrebo po nadaljnji obravnavi etičnih vprašanj, po povečevanju vseh tipov javnozdravstvenih kapacitet za povezano delovanje na področju digitalnega marketinga, po razvoju natančnega spremljanja ter pripravi in uveljavitvi učinkovite regulative digitalnega marketinga otrokom. K lj u č n e besede digitalno trženje, otroci, javnozdravstveni silos Digital marketing to children capacity building in Slovenia: linking public health silos DVIG ZNANJA NA P O D R O Č J U DIGITALNEGA T RŽ E NJ A OTROKOM V SLOVENIJI: POVEZOVANJE JAVNOZDRAVSTVENIH PO D R O Č I J Petra KLEPAC 1 , Mateja JUVAN 1 , Darina SEDLAKOVA 2 , Mojca GABRIJELČIČ BLENKUŠ 1 1 Nacionalni inštitut za javno zdravje 2 WHO Country Office Slovenia Kaj je znanega? Digital marketing is one of the important determinants of health and it is linked to all lifestyle areas which, directly or indirectly, public health is dealing with. Kaj je novega? Article is exploring the multidisciplinary competences and participatory approaches needed for crossing silos in digital marketing, which is innovative public health topic and calls for public health action. Navajajte kot: Klepac P et al. Digital marketing to children capacity building in Slovenia: linking public health silos. Javno zdravje 2018; 2(2): 9-13. Prispelo: 31. 8. 2018 Sprejeto: 27. 9. 2018 Korespondenca: mojca.gabrijelcic@nijz.si Članek je licenciran pod pogoji Creative Commons Attribution 4.0 International licence. (CC-BY licenca). The article is licensed under a Creative Commons Attribution 4.0 International License (CC-BY license). Strokovni čl an ek Javno zdravje 2018; 2(2): 9-13 www.nijz.si/revijajavnozdravje 10.26318/JZ-03-02 10 1 INTRODUCTION Noncommunicable diseases (NCDs) are a cause of 40 million deaths per year worldwide, of which 15 million are premature deaths (1). The European Region is the most affected of all the World Health Organization (WHO) regions by NCDs, which represent an estimated 77 % of the disease burden in the Region (2). WHO has listed prevention and control of NCDs among sustainable development goals (3) and has developed a global monitoring framework for preventing and controlling NCDs and their risk factors (tobacco use, unhealthy diet, physical inactivity, and harmful use of alcohol) (4). Gaming, gambling, and excessive use of the digital platforms (internet, computers, smartphones and similar electronic devices) have been also linked to NCDs (5). Exposure to marketing of these risky behaviours has been shown to promote them (e.g. 6, 7). Rapidly developing digital technologies and platforms allow for evolving of marketing. Innovative ways to enhance the impact of marketing include the collection of granular personal data from users, that enables digital platforms to further tailor marketing messages and to enhance the emotional persuasion (8, 9). These techniques are observed in marketing for many different products (alcohol, high fat, salt and/or sugar (HFSS) foods, gambling) and often operate across borders, posing a challenge to national policy-makers. In this short communication article/report, the term »digital marketing« (DM) refers to means of digital marketing communications, including digital advertising, online public relations, online sales promotion, web hybrid content, word-of-mouth spread of digital content etc. Children are especially vulnerable to the effects of DM, because (i) they are using digital platforms with access to a wide range of content for mixed ages (not child-specific) widely (10, 11, 12) and may be enjoying digital advertisements (13), (ii) they and their parents may not be sufficiently aware of the techniques used by DM (14, 15), and (iii) exposure to risk factors begins in childhood and the resulting non- healthy lifestyle may subsequently become a life-long habit. Tackling DM to children is therefore crucial in reducing burden of NCDs across the lifecourse (4, 16). 2 DIGITAL MARKETING INTITIATIVE IN SLOVENIA Slovenia is a founding member of the WHO European Action network on reducing marketing pressure to children since 2008. The meeting of the network in 2016 addressed the challenges of the DM to children (17). Processes and activities in digital environment, which are increasingly used in marketing communication were identified, including personal data collection and behavioural profiling, location targeting, use of social media, augmented reality, and online gaming (advergaming). Use of these approaches enables new practices of digital marketing communication-for example, targeting individual consumer according to real-time distribution of consumers or their past behaviour. Many gaps in knowledge were aslo identified, including limited access of governments/researchers to information on where exactly children are online in real time, extent of DM delivered to and seen by children, rapidly developing new techinques of the DM and their impacts, and the wider public attitudes to these issues. Effectiveness of increasing use of ad blockers by individuals to block DM was questioned and lack of updated framing/regulation in many countries to protect children from digital marketing channels was recognized as a challenge. It was also recalled that WHO´s Set of Recommendations on the marketing of foods and non-alcoholic beverages to children calls for a comprehensive policy approach that incorporates all media. The meeting called for public health to take a proactive stance in developing a well-argued rationale for action on digital marketing to children. WHO Regional Office for Europe published a report on tackling DM of food products to children, calling for immediate action by policy-makers to recognize and address the growing problem of DM targeted to children (16). The National institute of public health of Slovenia (NIJZ) recognized the need for awareness raising among public health experts, policy-makers, children and their parents, as well as public in general, and decided to launch a DM initiative, working across programmes. Importantly, knowledge capacity building and cross- silos working is needed to frame DM more effectively. In 2016, NIJZ organized a national workshop to provide basic cross-sectional analysis of current efforts to tackle (digital) marketing to children in Slovenia. Public health experts covering different “silos” (tobacco, alcohol, gaming and gambling, physical activity, nutrition, and others, including mental health) completed a questionnaire on rules applying to all possible channels of (digital) marketing to children and their effectiveness, the main challenges, key obstacles and key facilitators for improvement of the situation, and the most promising steps forward in reducing/restricting pressure in DM. The Agency for communication networks and services of the Republic of Slovenia (AKOS) also participated and clarified marketing practices and possible self-regulation, co- Strokovni čl an ek Javno zdravje 2018; 2(2): 9-13 www.nijz.si/revijajavnozdravje 10.26318/JZ-03-02 11 regulation and regulation approches. Participants concluded that it is necessary to work systematically on the evidence-based control of marketing to children and that DM is linked to all lifestyle factors that public health is dealing with. Joining forces in all lifestyle areas, tobacco, alcohol, gaming and gambling, physical activity, others (including mental health) – would mean defining and tackling common issues more efficiently, by identifying potentials and challenges and defining common goals and agendas. A report of the 2016 workshop with identified common cross-sectional issues was upgraded with inputs from public health experts from Slovakia and Austria. Comparative situational analysis in different lifestyle areas in all three countries (18) confirmed the need for international and intersectoral cooperation in this field and the fact that traditional media are more regulated than digital media, i.e. that legislation is not fit for purpose in the digital environment (outdated) and political will/consensus to act in the area of DM is missing. Also, self-regulation may not be successful. The analysis revealed, however, that DM in more traditional risk factors, such as nutrition, tobacco and alcohol, is more regulated as in the new emerging ones, such as gaming and gambling. Rules in restricting marketing specifically in physical activity lifestyle factor have not been detected by the countries. However, (excessive) use of digital platforms itself is linked with sedentary lifestyle (5), in addition, marketing of digital gaming and gambling should be closely monitored with regard to this risk factor. Developing of better monitoring of DM to children, mobilisation of public opinion pools, bringing forward citizens’ rights and raising their awareness were some of the highly recommended actions in the analyses (18, 19). This analysis served as a background paper for the »Capacity building workshop on Digital marketing to children - methodological challenges in linking public health silos« in October 2017 in Ljubljana, organized by NIJZ and WHO Country office in Slovenia (19, 18). The workshop aimed at exploring how to proceed in tackling DM of different lifestyle risk factors to children with a focus on common methodological grounds. Public health experts, government, international governmental agencies, academia, and civil society participated. Picture 1: Round-table style discussions on the capacities needed to work efficiently together in the area of DM to children. The lectures on principles of DM and importance for public health actions, legislative issues and technological options were followed by round-table »world cafe« style discussions on the capacities needed to work efficiently together in the area of DM to children (Picture 1), possible further steps, inhibitory and enabling factors in trying to tackle this area, and roadmap goals. Participants were randomly distributed into working groups and sequentially discussed all four topics. The discussions were guided by few initial questions and were spontaneous to stimulate creative thinking. The suggestions made were written down by Slovenian residents in public health separately for each topic. In the next step, participants voted for proposed measures and approaches in DM which they considered most important (Picture 2). Picture 2: Voting for prioritization of the public health actions in digital marketing. As a wrap-up, participants together formulated the workshop recommendations for further public health action. Most commonly voted public health actions were collected under the following subsections:  ethics,  governance and leadership,  framing and regulation, Strokovni čl an ek Javno zdravje 2018; 2(2): 9-13 www.nijz.si/revijajavnozdravje 10.26318/JZ-03-02 12  capacity building, and  research. Participants identified the need to:  take immediate action to elaborate ethical issues of DM to children,  cooperate intersectorally and internationally,  develop uniform definitions and common denominators in joint response of all public health “silos” to the common challenge of DM to children,  develop monitoring system for existing DM, to adopt and implement updated regulation covering DM to children including all kinds of media,  provide more resources for public health actions,  raise public awareness and improve digital media literacy, and  stimulate research fully characterising exposure to and impact of DM to children (18). A large proportion of the research focuses today on the role of DM in children’s nutrition and extension of the research on DM of other risk factors is needed (20). Even these existing findings, while informative, do not provide complete picture. In particular, exposure is likely underestimated, as researchers access to information on children’s exposure to and engagement with DM is limited by digital platforms, financial (and hence technical and analytical) and ethical barriers (16). More effective research methods are needed with extensive trans-disciplinary expertise, encompassing machine learning, mathematics, information technology, computational biology, psychology, children’s studies and more (16). The workshop (18) objectives to raise awareness and buildcapacities of the Slovene health promotion workforce were met and the workshop report was drafted. We believe that the workshop contributed to the work of WHO in compiling evidence and best practices to tackle the growing problem of DM to children. We propose to build further on existing tools in monitoring marketing of risk factors (e.g. 21, 22, 23) to fully reveal the challenge of DM. We have also recognized the importance of joining forces in all public health silos and the key recommendations for the future, included in the report, represent the first joint outcome. However, more capacities, in-depth knowledge and financial resources in particular, need to be accummulated through cooperation to define the common methodological grounds more precisely (18). 3 CONCLUSIONS DM is being recognized as an important and challenging determinant of health, easily reaching large audiences of children and becomming or even being a part of current social norms. Therefore, close monitoring and evidence-based framing of DM to children is needed. However, even in the absence of solid evidence, immediate action is needed to protect children from potential harms of the digital environment and to benefit from the positive effects of the digitalization of our social environments. Establishing DM to children as an independent lifestyle risk factor and area of ethics, governance and leadership, framing and regulation, capacity building and research while simultaneously joining forces in already established areas is the proposed action in the future. DM is an example how important it is to link the public health silos. It has been recognized as important public health action also by the European Commission and by the World Health Organization whose work in this area accelerated in the recent years with visible progress in 2018. The European Commission jointly addressed marketing in the field of nutrition and alcohol at JRC Expert Workshop in Ispra in May 2018 and the WHO Regional Office for Europe organised a workshop on digital marketing in the fields of nutrition, alcohol and tobacco in Moscow in June 2018. By described workshops and actions Slovenia added value in defining DM cross silo for different lifestyle factors and called to joint public health action at the international level. Tackling global public health challenge is not in the locus of control of an individual country but requieres joint public health action at the international level. At the national level, recommendations will be uptaken by the NIJZ and MoH, as the first step within the Slovene Healthy Schools Network, to reach children, teachers and parents. Topic is highly addressed also at the European Public Health Conference in Ljubljana in 2018. ACKNOWLEDGEMENTS The authors would like to thank the WHO Regional Office for Europe for supporting their work through the Biennial Collaborative Agreement with the Ministry of Health Slovenia, especially for the valuable technical inputs by Dr Jo Jewell and Dr Joao Breda. Likewise, they express their thankfulness to all workshop national and international participants without whom collecting of Strokovni čl an ek Javno zdravje 2018; 2(2): 9-13 www.nijz.si/revijajavnozdravje 10.26318/JZ-03-02 13 evidence and drafting the steps for the future needed interventions would not be possible REFERENCES 1. World health organization. Noncommunicable diseases. Fact sheet. (http://www.who.int/mediacentre/factsheets/fs355/en/, accessed 1 December 2017). 2. World health organization. Regional Office for Europe. Noncommunicable diseases. (http://www.euro.who.int/en/health- topics/noncommunicable-diseases, accessed 1 December 2017). 3. United Nations. Sustainable development goal 3: Ensure healthy lives and promote well-being for all at all ages (http://www.un.org/sustainabledevelopment/health/, accessed 1 December, 2017). 4. World Health Organization. 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