A health equity critique of social marketing: Where interventions have impact but insufficient reach

Department of Anthropology, Durham University, Dawson Building, South Road, Durham DH1 3LE, UK. Electronic address: .
Social Science [?] Medicine (Impact Factor: 2.56). 04/2013; 83:133-41. DOI: 10.1016/j.socscimed.2013.01.036
Source: PubMed

ABSTRACT Health interventions increasingly rely on formative qualitative research and social marketing techniques to effect behavioural change. Few studies, however, incorporate qualitative research into the process of program evaluation to understand both impact and reach: namely, to what extent behaviour change interventions work, for whom, in what contexts, and why. We reflect on the success of a community-based hygiene intervention conducted in the slums of Kathmandu, Nepal, evaluating both maternal behaviour and infant health. We recruited all available mother-infant pairs (n = 88), and allocated them to control and intervention groups. Formative qualitative research on hand-washing practices included structured observations of 75 mothers, 3 focus groups, and 26 in-depth interviews. Our intervention was led by Community Motivators, intensively promoting hand-washing-with-soap at key junctures of food and faeces contamination. The 6-month evaluation period included hand-washing and morbidity rates, participant observation, systematic records of fortnightly community meetings, and follow-up interviews with 12 mothers. While quantitative measures demonstrated improvement in hand-washing rates and a 40% reduction in child diarrhoea, the qualitative data highlighted important equity issues in reaching the ultra-poor. We argue that a social marketing approach is inherently limited: focussing on individual agency, rather than structural conditions constraining behaviour, can unwittingly exacerbate health inequity. This contributes to a prevention paradox whereby those with the greatest need of a health intervention are least likely to benefit, finding hand-washing in the slums to be irrelevant or futile. Thus social marketing is best deployed within a range of interventions that address the structural as well as the behavioural and cognitive drivers of behaviour change. We conclude that critiques of social marketing have not paid sufficient attention to issues of health equity, and demonstrate how this can be addressed with qualitative data, embedded in both the formative and evaluative phases of a health intervention.

Download full-text


Available from: Catherine Panter-Brick, Mar 01, 2015
1 Follower
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: In the spirit of critical reflection, we examine how the field of global health might surmount current challenges and prioritize its ethical mandate, namely to achieve, for all people, equity in health. We use the parlance of mastering deadly sins and striving for greater virtues in an effort to review what is needed to transform global health action. Global health falls prey to four main temptations: coveting silo gains, lusting for technological solutions, leaving broad promises largely unfulfilled, and boasting of narrow successes. This necessitates a change of heart: to keep faith with the promise it made, global health requires a realignment of core values and a sharper focus on the primacy of relationships with the communities it serves. Based on the literature to date, we highlight six steps to re-orienting global health action. Articulating a coherent global health agenda will come from principled action, enacted through courage and prudence in decision-making to foster people-centered systems of care over the entire lifespan.
    Global Health Action 03/2014; 7:23411. DOI:10.3402/gha.v7.23411 · 1.65 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Even in most egalitarian societies, disparities in care exist to the disadvantage of some people with chronic musculoskeletal (MSK) disorders and related disability. These situations translate into inequality in health and health outcomes. The goal of this chapter is to review concepts and determinants associated with health inequity, and the effect of interventions to minimize their impact. Health inequities are avoidable, unnecessary, unfair and unjust. Inequities can occur across the health care continuum, from primary and secondary prevention to diagnosis and treatment. There are many ways to define and identify inequities, according for instance to ethical, philosophical, epidemiological, sociological, economic, or public health points of view. These complementary views can be applied to set a framework of analysis, identify determinants and suggest targets of action against inequity. Most determinants of inequity in MSK disorders are similar to those in the general population and other chronic diseases. People may be exposed to inequity as a result of policies and rules set by the health care system, individuals' demographic characteristics (e.g., education level), or some behavior of health professionals and of patients. Osteoarthritis (OA) represents a typical chronic MSK condition. The PROGRESS-Plus framework is useful for identifying the important role that place of residence, race and ethnicity, occupation, gender, education, socioeconomic status, social capital and networks, age, disability and sexual orientation may have in creating or maintaining inequities in this disease. In rheumatoid arthritis (RA), a consideration of international data led to the conclusion that not all RA patients who needed biologic therapy had access to it. The disparity in care was due partly to policies of a country and a health care system, or economic conditions. We conclude this chapter by discussing examples of interventions designed for reducing health inequity.
    Bailli&egrave re s Best Practice and Research in Clinical Rheumatology 09/2014; 28(3). DOI:10.1016/j.berh.2014.08.001 · 3.06 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Recent public health policy and practice in the UK and beyond has promoted behavioural and lifestyle change as key methods for health improvement and the reduction of inequalities. These methods contrast with more upstream and structural interventions intended to address environmental and material determinants of health. A current exemplar of this approach is the use of social marketing. These changes represent a shift from the social to the individual as the target of public health interventions and raise a number of critical questions for health social scientists concerned not only with health improvement but also equity and social justice. Further, they can be identified as part of broader social and economic shifts that posit the individual as responsible for the management of their own bodies and selves in late modern societies characterised by ‘government at a distance’ and the repeal of welfare. This paper offers a review of shifting paradigms of public health and considers the implications of newer modes of health governance such as social marketing and their role as a modern form of health governance.
    Sociology Compass 09/2014; 8(9). DOI:10.1111/soc4.12196