Module 5: Social Marketing in Community-Based Health Care Delivery

Health-Seeking Behaviors

Examining health-seeking behaviors in resource-poor settings can provide insight into how people learn about health services, and what types of health services are most frequently accessed.  This information is essential to planning effective social marketing strategies targeted towards a specific population.

Case Study #1: Pakistan

An ethnographic evaluation assessed health-seeking behaviors and contributing factors to uptake of health services among citizens residing in the rural northern areas of Pakistan.  It was found that the driving forces behind health behaviors included socio-demographics, financial status, cultural preferences and beliefs, physical strength, environmental circumstances and health care service characteristics.  Untimely or overdue pursuit of health services could create “undesirable health outcomes, high fertility, unwanted pregnancies, medical complications, and amplified susceptibility to future illnesses.” (1)  Additionally, an unnecessary financial burden can be created for the patient if a straightforward illness becomes extended due to incorrect health-seeking actions.  A study conducted by Shaikh et. al. sought to explore the concept of “Where do they go, whom do they consult, and why?” in the northern areas of Pakistan, aiming to synthesize evidence-based information that would assist local government and healthcare providers in planning health policies.  The data was collected in 2004 - 2005, using ten same-sex focus groups with thirteen people each, held in various community venues (public centers, schools, offices, etc.).(2)  It was found that Pakistani patients seek out a variety of types of treatments and health care providers.  While hospitals and modern medicines are certainly utilized regularly, faith healers and more traditional healing techniques are popular methods, including home remedies learned from cultural leaders.  Another manner of treatment frequently practiced by locals is called the “hakeem” (Greco-Arab healer”), who uses indigenous medications to heal his patient.  As one participant noted, ”some get well from the hakeem’s medicine and some do not, but people still prefer to go to him.  This type of approach has existed from the beginning as a tradition.”(3)

The reasoning behind selecting a certain healthcare supplier is often swayed by factors such as accessibility, vicinity, and convenience; for example, the majority of residents in the northern areas attend “khalifa” because there is generally one in each village, and they have many available hours.  Those living in close proximity to a hospital would confer with a trained provider immediately, but others do not if they do not have easy access, transportation, or sufficient finances.  Additionally, cultural beliefs can serve as barriers to eye care (See Community-Level Challenges in Global Health Delivery), such as the practice that if a woman or child falls ill, the male members of the house automatically make the decisions about health plans.  The woman must oftentimes be granted permission from a man to seek healthcare from a government-run hospital or health center, but is in some situations allowed to go to a khalifa by herself, which makes this option easier and therefore often more appealing.(4)

Both the physical and cultural barriers to accessibility have tremendous implications for social needs and social marketing.  Services should be made more widely available so that mountain dwellers do not have to travel such far distances to see a trained physician, and hospitals should make adjustments to suit the cultural preferences of their audience by hiring more female staff members and developing a more client-centered approach to health care.  It is imperative that these adjustments are not only established within the current system, but that they are sufficiently advertised to locals, so that rural Pakistani health-seeking habits will change accordingly.  As demonstrated by the residents’ choice to consult the hakeem because it is longstanding tradition (even though individuals are often not cured afterwards), people do not fully understand or appreciate that seeking healthcare from a trained physician would actually be more likely to help them overcome their ailments.  Overall, social elements need to be taken into account when forming public health policies, instead of simply creating policies that consider only the delivery of health care services.  It would be beneficial, for example, to implement laws that would limit the over-the-counter exchanges of potent medicines that are currently being carried out by those who are not physicians.  Social marketing is the way to convey this important health message.  While this case study has been very informative in terms of health-seeking behaviors in this one area, further research should be conducted, and other districts of the northern areas of Pakistan should be examined to better comprehend the motivation behind certain health behaviors in resource-poor rural areas.

Case Study #2: Bangladesh

In Bangladesh, the sociological and behavioral features of malaria were examined in order to construct an effective prevention and control system.  A survey was carried out from July to November 2007, conducting face-to-face interviews in thirteen malaria-endemic districts, and the overall prevalence rate was determined to be 3.1% by using the Rapid Diagnostic Test.  The results demonstrated that participants’ knowledge of the transmission, prevention, and treatment of malaria was not extensive, and that the bulk of infected patients did not seek treatment.   Those who did actively obtain help consulted primarily with village "doctors" and drugstore salespeople instead of with trained physicians.(5)

The absence of sufficient data to direct the planning and application of “prevention, management, and control strategies” for malaria in resource-poor regions such as Bangladesh creates a large void that must be filled.  In places such as India, Turkey, Nepal, or Haiti where malaria is quite common, most people are aware that a mosquito causes the infection, yet very few can explain the exact process of transmission or how the mosquito originally became virulent.  Those living in poverty with low literacy had a particularly difficult time understanding the cause of the disease.  In order to be effective, health education programs should be created based on the current background understanding and awareness of the target audience, and the population’s existing health-seeking habits should be noted.  In addition to disseminating information materials in print and electronic forms, other casual communication techniques should be used in order to connect with the illiterate, such as culturally sensitive songs or theater performances.   These marketing techniques will help raise awareness in resource-poor locations.(6) The study also detected that even though many of the survey respondents knew how critical bed nets were in preventing mosquito bites, and even though they indicated an understanding about the importance of seeking treatment, the majority of infected people either did not seek treatment or consulted local villagers instead of trained doctors.  Therefore, another target point of education for marketers should be the importance of “Early Diagnosis and Prompt Treatment (EDPT)”.(7)

Case Study #3: Kenya

A 2009 study conducted in Kenya explored how demand for a product depends on techniques such as framing of marketing messages or differences in gender.  A malaria control device in this study was used as the merchandise that was intended for use in rural households.  The study evaluated the effects of two psychological behavioral models used to sell the product.  One strategy involved changing the framing of the product’s advantages, causing the patient to perceive it in a certain intended way, a technique known as “framing effects”.  The second, known as “foot in the door” marketing, involves making the person verbally promise that they will buy the product.  Interestingly, the study discovered that both of these strategies were statistically insignificant in this particular setting.  Instead, uptake of a given product was contingent on price, and purchase was generally associated with household income.(8)

Rural market households in a zone of widespread malaria in Western Kenya were used as the study subjects.  Out of the approximately 150 households, each was randomly assigned to “a subsidy level; one of three ‘marketing’ groups, one of two ‘commitment’ groups, and one of three ‘targeting groups’.”  Unsurprisingly, the wealthier and better educated families had a considerably greater rate of family members already regularly sleeping under the protection of antimalarial bed nets.  The overall marketing lesson learned is that the Western Kenyans were sensitive to price, but were not influenced by the psychological techniques that were tested, regardless of gender.  Even after verbally committing to purchasing a net, people did not feel obligated, perhaps because they simply did not have the funds to do so.  “Liquidity constraints” serve as the primary challenge for households to invest in long-lasting insecticide treated nets.  This is a factor that marketers should be sensitive to, perhaps by offering the option of purchasing nets on credit so that everyone can afford one.(9)

How is Healthcare Best Marketed? Application of Social Marketing

The Struggle of Treating HIV: Background

Organizations have started to implement social marketing strategies as a way to tackle the most immense and complex health problems such as HIV.  HIV is not only a devastating illness, but it also impact the economy.  A vicious cycle prevails as more and more individuals and families fall victim, making it increasingly difficult to escape the epidemic.  Illnesses associated with HIV can lead to loss of wages, which leads to restriction of food consumption, leading to weakened overall health and an even further weakening of the immune system.  This causes more diseases to be contracted, which requires more care and frequently leads to parents removing their daughters from school.  Consequently, these young women grow up to be both parentless and illiterate, meaning that they are uninformed about HIV prevention, make less money, and have an increased likelihood of performing sexual favors to make a living.  This combination of factors puts these girls at greater risk to contract HIV themselves.  As Chance and Desphande emphasize in their article “Putting Patients First: Social Marketing Strategies for Treating HIV in Developing Nations,” a sustainable HIV solution must be affordable for patients, yet must also create sufficient revenue for the provider to continue medicating a substantial cohort of HIV-positive individuals.(10)

Consumer Centric Marketing vs. Traditional Pharmaceutical Marketing

The “consumer-centric marketing paradigm” refers to a stakeholder model, where drug producers and the government work together to ensure that all consumers are getting what they need, even if they are unable to pay.  While traditional pharmaceutical companies concentrate their marketing energies on physicians, consumer-centric drug companies identify their consumer as the patient.  This philosophy creates opportunities for markets where there are not currently any, particularly among those who cannot afford patented drugs.  In order to ensure that the product will be sold to consumers at the absolute minimum cost, consumer-centric strategies prioritize making small investments that are low risk.  This differs from a traditional drug firm’s model of pricing medicine, which is “technology-pushed rather than market-pulled” and requires investments of about $500 million USD to design a novel drug and market it to wealthy nations.(11)

The core difference between the two marketing techniques is that while big business methods consist of “building demand for existing products through heavy marketing expenditures in high-volume global markets,” the consumer-centric organizations “strive to meet potential demand in a dynamic marketplace.”(12)  The secrets to being profitable are to remain flexible and adaptable regardless of the circumstances, and to foster a skillful balance between being market-driving and market-driven.  Consumer-centric drug producers react to the challenges of market unpredictability with three core principles:

1. Aim to reduce market insecurity and ambiguity in all possible ways, and foster minimum prices via “preorder, prepay manufacturing.”

2. Maintain communication with buyers to anticipate future positive prospects or potential dangers.

3. Continue to create plans and ideas throughout the process, seeking out collaborations at any possible time.

In summary, a consumer-centric approach can be described as “opportunistically cooperative” in contrast to the more “defensive” traditional pharmaceutical methods.  People should be served on both the individual and community levels, and users should understand the profits that they have gained.(13)

Aspen Pharmacare: A Consumer-Centric Model

Aspen Pharmacare is one organization in Africa that owes its widespread success to the consumer-centric model, embodying both reliable financial standings and an incomparable capability in business diplomacy.  The key is that it recognizes patient needs and desires first, and then strives to design an economically practical solution. In 2004, the South African government became entangled in American politics, experiencing strong pressures to discuss the nation’s new AIDS relief system from both the Clinton Foundation (an NGO founded by former President Clinton) and PEPFAR (President-at-the-time George Bush’s “President’s Emergency Plan for AIDs Relief).  While both plans had a potential for undesirable consequences, Aspen Pharmacare assisted the South African government with the advantages that each plan offered. Aspen Pharmacare focused on the commitment to patient care and collaborative business connections.(14)

Aspen Pharmacare was the first firm in Africa to go into the ARV (antiretroviral drug) market, and in collaboration with the national government, the firm introduced a “licensed version of American Bristol-Myers Squibb’s patented stavudine in 2003, followed by German Bohringer Ingelheim’s nevirapine for preventing mother to child transmission, and British GlaxoSmithKline’s lamivudine/zidovudine cocktail in 2004.”(15)  Since Aspen Pharmacare was creating patented drugs, it qualified to receive financial backing from PEPFAR, and Aspen Pharmacare became the first generic firm to earn approval from both PEPFAR and the FDA.  Furthermore, the price of manufacturing remained small enough to offer drugs at the Clinton Foundation’s ground cost, allowing the firm to also be the first approved by the Clinton Foundation.  Aspen Pharmacare continued to negotiate agreements and seek out opportunities, earning the rights to sell Gilead Sciences’ ARVs in 95 countries, and signing onto a joint project with Indian drug company Maxtrix with the mission “to strengthen vertical integration into active pharmaceutical ingredients APIs, the costliest component of the drugs.”(16)  By joining forces with competitors, the firm was able to expand the ARV market in South Africa, simultaneously saving lives and improving as an increasingly prosperous company.

Footnotes

(1) Shaikh, B. T., Haran, D., & Hatcher, J. (2008). Where do they go, whom do they consult, and why? Health-seeking behaviors in the northern areas of Pakistan. Qualitative Health Research, 18(6), 747-755.

(2) Ibid.

(3) Ibid.

(4) Ibid.

(5) Ahmed, S. M., Haque, R., Haque, U., & Hossain, A. (2009). Knowledge on the transmission, prevention and treatment of malaria among two endemic populations of Bangladesh and their health-seeking behaviour. Malaria journal, 8(1), 173.

(6) Ibid.

(7) Ibid.

(8) Dupas, P. “What Matters (and What Does Not) in Households’ Decision to Invest in Malaria Prevention?”  American Economic Review: Papers and Proceedings, vol. 99 no. 2, pp 224-230, (May 2009). 

(9) Ibid.

(10) Chance, Z., & Deshpandé, R. (2009). Putting patients first: social marketing strategies for treating HIV in developing nations. Journal of Macromarketing, 29(3), 220-232.

(11) Dupas, P. “What Matters (and What Does Not) in Households’ Decision to Invest in Malaria Prevention?”  American Economic Review: Papers and Proceedings, vol. 99 no. 2, pp 224-230, (May 2009). 

(12) Ibid.

(13) Ibid.

(14) Dupas, P. “What Matters (and What Does Not) in Households’ Decision to Invest in Malaria Prevention?”  American Economic Review: Papers and Proceedings, vol. 99 no. 2, pp 224-230, (May 2009). 

(15) Ibid.

(16) Ibid.