Social Science & Medicine 110 (2014) 18e25
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Review
Social marketing of water and sanitation products: A systematic review of peer-reviewed literature W.D. Evans a, *, S.K. Pattanayak b, S. Young a, J. Buszin c, S. Rai b, Jasmine Wallace Bihm a a
The George Washington University, 2175 K Street, NW, Suite 700, Washington, DC 20037, USA Duke University, Sanford Institute of Public Policy, 126 Rubenstein Hall, Durham, NC 27708, USA c Population Services International, 1120 19th Street, NW, Washington, DC 20036, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 26 August 2013 Received in revised form 23 January 2014 Accepted 12 March 2014 Available online 21 March 2014
Like commercial marketing, social marketing uses the 4 “Ps” and seeks exchange of value between the marketer and consumer. Behaviors such as handwashing, and products such as those for oral rehydration treatment (ORT), can be marketed like commercial products in developing countries. Although social marketing in these areas is growing, there has been no systematic review of the current state of practice, research and evaluation. We searched the literature for published peer-reviewed studies available through major online publication databases. We identified manuscripts in the health, social science, and business literature on social marketing that used at least one of the 4 Ps of marketing and had a behavioral objective targeting the behaviors or products related to improving water and sanitation. We developed formalized decision rules and applied them in identifying articles for review. We initially identified 117 articles and reviewed a final set of 32 that met our criteria. Social marketing is a widespread strategy. Marketing efforts have created high levels of awareness of health threats and solutions, including behavior change and socially marketed products. There is widespread use of the 4 Ps of marketing, with price interventions being the least common. Evaluations show consistent improvements in behavioral mediators but mixed results in behavior change. Interventions have successfully used social marketing following widely recommended strategies. Future evaluations need to focus on mediators that explain successful behavior change in order to identify best practices and improve future programs. More rigorous evaluations including quasiexperimental designs and randomized trials are needed. More consistent reporting of evaluation results that permits meta-analysis of effects is needed. Ó 2014 Elsevier Ltd. All rights reserved.
Keywords: Social marketing Health promotion Behavior change Water Sanitation Diarrheal disease
1. Introduction At its core, marketing is about an exchange of value between the marketer and consumer. If the marketer can promote a product or service to make the consumer perceive sufficient value, the consumer is more likely to purchase it. The marketer’s objective is to create value for consumers and thereby financial benefit for the marketer or her clients. Social marketers use the same powerful idea in a different way e not to sell products and services for the benefit of the marketer but to promote socially beneficial causes
* Corresponding author. E-mail addresses: [email protected] (W.D. Evans), subhrendu.pattanayak@ duke.edu (S.K. Pattanayak), [email protected] (S. Young), [email protected] (J. Buszin), [email protected] (S. Rai), [email protected] (J.W. Bihm). http://dx.doi.org/10.1016/j.socscimed.2014.03.011 0277-9536/Ó 2014 Elsevier Ltd. All rights reserved.
and behaviors for the benefit of the audience (Hastings, 2007). A growing body of evidence shows that marketing is highly effective in this arena as well (Evans et al., 2008). Like commercial marketing, social marketing uses the basic principles of the “marketing mix”, or 4 “Ps” of place, price, product, and promotion (Borden, 1964; Kotler and Lee, 2008). Just as a brand of toothpaste can be effectively marketed by making it available to consumers in convenient locations, pricing it right relative to competitors, endowing it with attractive perceived benefits, and advertising it in persuasive ways with sufficient frequency, behaviors such as handwashing and treatment products such as those for oral rehydration salts (ORS) can also be marketed. In the case of handwashing, we may need to think differently about factors such as ‘price’ (time and effort, or convenience) and ‘product’ (the social or functional benefits gained from the behavior) but the basic approach is the same (Evans and Hastings, 2008).
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Recently, there has been growth in social marketing to promote healthy drinking water and sanitation practices, as well as treatments to prevent water-related illnesses such as diarrheal disease (Devine, 2008; Freeman et al., 2009). However, to date there have been no known efforts to systematically review and assess the extent, nature, and evidence of effectiveness for social marketing in global water and sanitation programs. The purpose of this paper is to systematically review the published literature on this topic and evaluate the state of practice and evidence in the field. Specifically, we sought to identify 1) the presence or absence of specific social marketing activities in each intervention, 2) the presence or absence of each of the 4 Ps of marketing in the interventions, and 3) the outcome of the evaluation conducted in these social marketing interventions. Based on results of this review, we discuss the need for interventions that incorporate more Ps, more outcomes research, and more research on the effectiveness of specific intervention strategies and combinations of the 4 Ps. 2. Methods We conducted a systematic search of the published, peerreviewed literature using all relevant major online research literature databases (specified below) and following widely accepted methods for systematic review (Higgins and Green, 2011). We note that social marketing and interventions focused on water and sanitation are also widely represented in unpublished reports and other ‘gray’ literature. However, we focused on peer-reviewed literature in order to ensure quality of evidence and consistency with accepted systematic review practices. We identified as relevant any manuscripts in the published health, social science, and business literature that used at least one of the 4 Ps of marketing, had a behavioral objective targeting water and sanitation related behaviors, and had a health objective targeting diarrheal disease. We based the review methodology in part on methodologies from a previous review of branded social marketing campaigns conducted by the lead author (Evans et al., 2008). Specifically, we searched the following health, social science, and business databases: PubMed, PsycINFO, Web of Science (includes Science Citation Index Expanded, Social Sciences Citation Index, and Arts & Humanities Citation Index), Communication & Mass Media Complete, Academic Search Premier, Business Source Premier, CINAHL, Health Source: Nursing/Academic Edition, and Health Source: Consumer Edition. Search terms included the following: Diarrhea/Diarrhoea, Hygiene, Water, Sanitation, Social Marketing, Health Promotion, Health Communication, Community Intervention, Community Health, Behavior Change. We selected these terms based on the authors’ experiences in the field and conducting previous reviews, and in consultation with a medical research librarian. For completeness, we also searched literature known to the authors, including publications on water and sanitation intervention studies in the developing world. In particular, the bibliographies of two recent meta-analyses on social marketing and mass media intervention were reviewed and potential citations screened following the methods described (Snyder et al., 2004; Grilli et al., 2002). We searched all sources listed above in the date range of 1991e June 2013). Based on this process, we created a database of all 352 unduplicated articles on social marketing interventions regarding diarrhea and water or sanitation. We immediately excluded 235 articles regarding ‘breastfeeding and diarrhea’, ‘zinc supplementation and diarrhea’, and articles that did not include an intervention of any kind. After this initial phase, we identified 117 articles.
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Next, we reviewed the articles based on our specific criteria for inclusion in study. Namely, we screened them for reports on interventions that: 1) were original research (not review papers, meta-analyses, or commentaries); 2) utilized some form of social marketing principles (i.e., reported on use of 1 or more of the four Ps); 3) targeted behavior relating to water or sanitation; and 4) targeted diarrhea prevalence and/or morbidity as a health objective. We also screened to ensure the articles included specific reports of evaluation or implementation of social marketing activities, defined as coordinated efforts to promote, distribute, or use pricing strategies to encourage adoption of various products aimed primarily at diarrheal disease prevention. Based on this indepth screening process, we excluded 85 articles and identified 32 articles for inclusion in the study. Fig. 1 summarizes the review process. Note that due to the diverse nature of the literature on social marketing interventions in this area, and the varying methods of reporting outcomes, we chose not to attempt a meta-analysis of effects of reviewed interventions on behavior. Rather the purpose of this paper is to describe the nature of the interventions and literature, hopefully promoting more uniform reporting of outcomes in future. Once the review sample of articles was identified, the first two authors individually read each of the articles in-depth and coded them for specific content reported in the results section. The results of all reviews were compiled and discussed by the reviewers. Potential sources of differences in assumptions and approach in coding articles were identified and discussed. A consensus was reached about coding, and common procedures adopted where discrepancies had been identified. 3. Results Table 1 provides a summary of basic information gleaned from each water and sanitation article reviewed. The articles dealt with interventions relating to household water treatment, handwashing, safe disposal of feces and personal hygiene. The studies covered 14 developing countries, mostly in South Asia and Africa. The interventions used a wide range of health communication and social marketing strategies, including mass media, interpersonal communication (IPC), community outreach and visits to households by health workers. New and social media, while rapidly growing forms of communication, were not identified as strategies in any of the reviewed papers. High levels of awareness of the promoted health messages were reported. Table 2 provides a summary of the topic areas that were the focus of social marketing interventions. Most interventions focused on behaviors practiced inside the home, such as handwashing, point-of-use water treatment, dishwashing and various hygiene practices. Several interventions incorporated more than one desired behavior, such as appropriate water storage in combination with point-of-use water treatment. Table 3 provides a summary of the social marketing development described in the water and sanitation articles reviewed. In some cases, studies described specific scientific theories used in the development of the social marketing effort used. Psychology and communication theories were the most commonly used theories, found in 26% and 23% of the studies reviewed, respectively. Some of the articles described intervention efforts based in formative research such as interviews and focus groups. Examination of the studies in terms of the use of the 4 Ps of marketing revealed a majority using each of the four marketing techniques. Almost all articles (96.8%) used “product” and “promotion” marketing techniques. The product P was represented by 1) safe water treatment products and 2) behavioral product approaches in which hand-washing and
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Fig. 1. PRISMA diagram of systematic review process.
sanitation behaviors were marketed as having social and functional benefits. The price P was only explicitly addressed in the safe water treatment product interventions, with subsidies to reduce costs of the marketed systems used to encourage purchase and use. The place P was represented by 1) community-based sales approaches, 2) home visit approaches, and 3) health clinics to simplify distribution. The promotion P was represented by mass advertising, community outreach, use of branded gear such as t-shirts, and promotion by health care providers at clinics. Community outreach was a heavily utilized marketing channel present in 96.8% of the intervention efforts. Table 4 provides a summary of the study design and outcomes in the water and sanitation articles reviewed. Most of the articles reviewed described studies with an observational design; the remaining studies were equally split between experimental and quasi-experimental designs. Almost all articles reported on the study sample size and sample characteristics. Multivariate analysis was used to report statistics in over half of the studies. Most of the studies (75%) aimed to assess behavioral objectives and clearly stated these objectives. Almost all of these studies reported product/behavior awareness or reactions to the interventions. 4. Discussion Tables 1e4 outline various aspects of the studies that used social marketing in water and sanitation interventions. We analyzed
activities that each of the interventions used and examined the extent to which they incorporated the four Ps of social marketing. 4.1. Product Over a third of the studies reviewed used the Safe Water System, which promotes point-of-use water treatment (specifically a sodium hypochlorite solution), safe storage and behavior change. The sodium hypochlorite solution is marketed under different names Sur’ Eau in Madagascar, Klorin in Kenya, WaterGuard in Malawi e but is always locally produced and sold. The use of a distinctive brand name and logo echoes the marketing techniques used by the private sector to ensure product differentiation. However not every intervention employed such a strategy. In Dongre et al. (2008), for example, unbranded faucet-fitted earthen vessels were sold to consumers in India; in Nanan et al. (2003) and Pattanayak et al. (2009), the programs provided unmarked latrines to rural households in Pakistan and India. Branding can also extend to the entire campaign. In Ahmed et al. (1993), hygiene behaviors in Bangladesh were marketed under a “Clean Life campaign”. The product, in both the Safe Water System and other interventions, is in some cases behavioral or attitudinal. Every reviewed study also had as a product the health gains that arose from a hygiene-related behavior like handwashing, water treatment or safe disposal of feces.
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Table 1 Overview of studies in this review. Topic area
Citation
Public health campaign
Research design
Location
Safe water system Safe water system
Dunston et al. (2001) Makutsa et al. (2001)
Paired study; randomized Non-experimental
Madagascar Kenya
Safe water system Point-of-use water treatment
Quick (2003). Parker et al. (2006)
Safe Water System (Sûr’Eau) Water, Sanitation, and Education for Health (WASEH) Project Safe Water System (SWS) Safe Water System (SWS)
Zambia, Madagascar, Kenya Kenya
Handwashing; safe disposal of feces Handwashing; dishwashing
Curtis et al. (2001)
Saniya
Pinfold (1999)
Faucet-fitted earthen vessels; point-of-use water treatment Safe Water System
Dongre et al. (2008)
Social marketing e (posters and curriculum within schools, leaflets, stickers, handwashing containers, posters Community-Led Initiatives for Child Survival (CLICS) program
Experimental; field trials Non-experimental; Paired Study Observational study; randomized Experimental; microbiological indicators (fingertip contamination Quasi-experimental
India
Quasi-experimental
Kenya
Handwashing; point-of-use water treatment; use of local vessels Handwashing; point-of-use water treatment Handwashing
Luby et al. (2004a, b)
Quasi-experimental
Pakistan
Cluster randomized control
Pakistan
Luby et al. (2004a, b)
Children’s books, notebooks, pens and pencils The Karachi Soap Health Study
Pakistan
Handwashing
Luby et al. (2005)
The Karachi Soap Health Study
Hygiene practices; infrastructure Hygiene practices
Nanan et al. (2003)
Water and Sanitation Extension Programme (WASEP) project Participatory health education with students; peer training among students Social marketing techniques to promote dishwashing and hand washing Point-of-use water disinfection; safe storage; community education; weekly visits by community health workers Water treatment with bleach, safe storage, and behavior-change communications Safe Water System, “Waterguard” Safe Water System, “Clorin” Safe Water System, “Clorin” Safe Water System, “Clorin” Promotion through nurses at health clinics e use of IPC, video presentations and leaflets Capacity building and empowerment School-based water, sanitation, and hygiene (WASH) intervention “Waterguard”
Cluster randomized controlled trial Cluster randomized controlled trial Case Control
Pakistan
Quasi-experimental
Kenya
Quasi-experimental
Thailand
Quasi-experimental
Bolivia
Observational
Kenya
Observational Experimental Experimental Experimental Quasi-experimental
Malawi Zambia Zambia Zambia Peru
Repeat cross-sectional Cluster randomized trial
Kenya Kenya
Experimental
Kenya
Experimental
Nepal
Observational Observational Experimental Experimental Experimental Retrospective ecological study
Australia Malawi Guatemala Uganda Zambia Kenya
Handwashing; dishwashing Point-of-use water treatment; safe storage
Garrett et al. (2008)
Luby et al. (2006)
Onyango-Oumaa et al. (2005) Pinfold and Horan (1996) Quick et al. (1999)
Safe water system
Migele et al. (2007)
Safe water system Safe Water System Safe Water System Safe Water System Feces disposal; appropriate places for defacating
Stockman et al. (2007) Thevos et al. (2003) Thevos (2000) Thevos (2000) Yeager et al. (2002)
Hygiene; sanitation Hand washing; water treatment; latrines Hand hygiene; drinking water treatment and storage Zinc-promotion
Kariuki et al. (2012) Greene et al. (2012)
Handwashing Water treatment Water treatment Water treatment and storage Water treatment and storage Safe water system
McDonald et al. (2011) Wood et al. (2012) Luby et al. (2008) Lule et al. (2005) Quick et al. (2002) John et al. (2007)
Ryman et al. (2012) Wang et al. (2011)
Water, Sanitation, and Education for Health (WASEH) Project Home-based intervention
Social Marketing Plus for Diarrhoeal Disease Control: Point of Use Water Disinfection and Zinc Treatment (POUZN) project “No Germs on Me” “Waterguard” Marketing of flocculant-disinfectant Safe water system Safe water system Safe water system
4.2. Place Place in social marketing refers to the distribution channels and outlets through which tangible products are made available to consumers. In the case of health-related behaviors, place could also mean the location where the consumer performs the desired behavior, or accesses information about the product. Where the interventions surveyed involved the transactional exchange of a tangible product, the programs tried to facilitate availability and easy access by utilizing local resources.
Burkina Faso Thailand
Pakistan
In Madagascar, for example, community-based sales agents were trained to provide the sodium hypocholorite solution (Dunston et al., 2001). In Karachi, Pakistan, fieldworkers visited households to distribute soaps for handwashing (Luby et al., 2005), while lidded storage vessels were distributed along with water treatment solutions to households in Nicaragua (Macy and Quick, 1998). Programs also used home visits to promote health related behaviors. Volunteers in Burkina Faso trained volunteers to conduct monthly house-to-house visits to educate households about the
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Table 2 Topic area (n ¼ 32).a
Table 4 Study design and outcomes (n ¼ 32).
Variables
Frequency
%
Variables
Safe water system Point-of-use water treatment Handwashing Dishwashing Improved water supply Use of local vessels Infrastructure Appropriate places for defecating/Safe disposal of feces Ground sanitation Hygiene practices Latrines Safe storage
10 12 9 2 1 2 1 3 1 3 2 4
31.3 37.5 28.1 6.3 3.1 6.3 3.1 9.4 3.1 9.5 6.3 12.5
Research design Experiment Quasi-experiment Observational study Sample size reported Sample characteristics described Response ¼ follow-up rate reported Statistics reported Descriptive Multivariate analysis (ANOVA ¼ regression) Path analysis None Reported Objectives clearly stated Product/behavior awareness or reactions Pre-behavioral outcomes Behavioral outcomes Effects reported Product/behavior awareness or reactions Pre-behavioral outcomes Behavioral outcomes Estimate of precision reported
a
Several articles addressed multiple topics.
benefits of handwashing and safe disposal of feces (Curtis et al., 2001). Where the intervention involved performances or the use of print or visual media, public spaces in the community were also utilized. In northeastern Thailand, for instance songs about hygiene messages were broadcast through village loudspeakers (Pinfold and Horan, 1996). Researchers used weekly prayer meetings at local mosques in rural Bangladesh to talk about cleanliness as a common goal (Ahmed et al., 1993). Targeted interventions also focused on specific groups. In a study in western Kenya, for example, health education was given to schoolchildren in grades three and five using drawings, role-play, songs and poems (Onyango-Ouma et al., 2005). 4.3. Price Price in social marketing could refer to the provision of monetary subsidies (about whose effectiveness there is considerable disagreement) or the costs of time and effort that individuals and households have to bear in adopting the intervention. For the purposes of this paper, however, we focus on monetary subsidies/ incentives. In interventions that used the Safe Water System, household water treatment solutions were sold at subsidized rates, typically a Table 3 Social marketing development (n ¼ 32). Variables Scientific theory Communication Marketing Psychology Other Formative research Focus groups Interviews Other Marketing P’s Product Price Place Promotion Marketing channels Paid mass media Unpaid mass media Earned media Community outreach Community mobilization Mobile phones Social media (not Mobile) Other marketing techniques Audience segmentation Message tailoring Other
Frequency
%
7 2 8 1
21.9 6.3 25.0 3.1
10 9 2
31.3 28.1 6.3
31 20 26 31
96.9 62.5 81.3 96.9
13 4 0 31 19 0 0
40.6 12.5 0.0 96.9 59.4 0.0 0.0
16 3 0
50.0 9.4 0.0
Frequency
%
9 9 14 30 26 12
28.1 28.1 43.8 93.8 80.6 38.7
10 18 1 2
31.3 56.3 3.1 6.3
18 17 24
56.3 53.1 75.0
28 12 27 24
87.5 37.5 84.4 75.0
small fraction of the market price. In Madagascar, for instance, sodium hypocholorite solution was sold at 30 cents for a 500 ml bottle (Dunston et al., 2001), while in western Kenya, the price was 33 cents a bottle (Makutsa et al., 2001; Garrett et al., 2008). In Wardha, India, a 50 ml bottle was sold for 30 cents, along with an earthen vessel fitted with a plastic faucet (Dongre et al., 2008). Similarly, in Zambia, water vessels were supplied at subsidized rates (Thevos et al., 2003). Water treatment solutions were also sold at reduced prices to wholesalers and retailers to stimulate sales (Makutsa et al., 2001). In addition, health workers also sometimes received small commissions as incentives (Garrett et al., 2008). Where the intervention took the form of investments in sanitation infrastructure, households were often asked to bear part of the costs of construction. For instance, CARE Kenya paid for 40% of the costs for providing new latrines in rural communities, but households were expected to pay the remaining 60%, and also provide labor for the latrine construction. Similarly, in a community-led sanitation intervention in Orissa, India, households below the poverty line had to pay 15% of the cost of a new latrine, while other households paid the entire cost (Pattanayak et al., 2009). Another solution, called WaterGuard, was initially distributed at low cost and later provided freely at antenatal women in order to overcome cost barriers (Wood et al., 2011). 4.4. Promotion Promotion is perhaps the most visible aspect of social marketing. It aims to generate demand for the product by imparting information and changing attitudes. Most of the water and sanitation intervention surveyed used extensive promotion techniques. One common strategy e used in interventions in Burkina Faso, Pakistan, Uganda and Bolivia e was to train local health workers/volunteers to impart hygiene education through household visits. Another strategy was to organize neighborhood meetings to promote awareness of hygiene behaviors. For example, in Wardha, India, community-based village co-ordination committees were formed to act as go-betweens between households and program workers (Dongre et al., 2008). Some studies focused on particular spaces of interaction, like clinics and schools. For instance, in Homa Bay, Kenya, nurses at a maternal and child health clinic were trained to communicate
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information about water chlorination to their clients (Parker et al., 2006). Schoolchildren too can sometimes act as health behavior change agents. In Bondo, western Kenya, schoolchildren underwent participatory health communication training, where they learnt about hygienic behaviors through songs, poems and drawings (Onyango-Ouma et al., 2005). Print and electronic media were used in several studies to disseminate hygiene-related information. Advertisements on radio, television and in newspapers, pamphlets and signs on buses, walls and billboards were just some of the techniques used. Some interventions used community-related activities to get the message of hygiene out. In Nyanza, Kenya, program workers organized soccer tournaments and Klorin quizzes to spread awareness about their product (Makutsa et al., 2001). In Thailand, comic books and T-shirts were developed to support program activities (Pinfold, 1999). 4.5. Design and impacts of interventions that employ social marketing: water treatment at the household level In the 1990s, The Centers for Disease Control and Prevention (CDC) and the Pan American Health Association (PAHO) designed the “Safe Water System,” an intervention using point-of-use treatment, proper storage, and behavior change to improve water safety in developing countries. The behavior change component of the intervention employs media campaigns, community mobilization, and interpersonal communication techniques to increase the connection made between water quality and disease (Centers for Disease Control and Prevention, 2013). Organizations such as CARE International and Population Services International (PSI) have used the Safe Water System (SWS) framework to promote household-level water treatment in nineteen countries across five continents. Participating organizations have often grounded the intervention, tailoring the social marketing component to fit the particular needs of each target community. For example, in Madagascar, CARE and PSI used branding and media campaigns in conjunction with community mobilization in a randomized study to promote the use of the point-of-use treatment system and increased sales from 76,000 bottles in March 2000 to 250,000 bottles in December of the same year (Dunston et al., 2001). CARE also implemented the SWS intervention in Western Kenya and used social marketing and motivational interviewing combined with subsidized prices to promote home water treatment and safe storage. A non-experimental study found that the project resulted in adoption rates of 33.5% for chemical water treatment and 18.5% for clay pots modified for safe water storage (Makutsa et al., 2001). When CARE used the SWS intervention in southern Kenya in another non-experimental study, they grounded the intervention to the target community by incorporating social marketing with a nurse training program focused on the six steps of proper handwashing. One year later, 71% of clients of the clinic had chlorine residuals in their drinking water and 34% were observed using proper hand washing techniques (Parker et al., 2006). Motivational interviewing has been found to be an effective technique for promoting SWS adoption and promotion of behavior changes, as described below, in several African countries (Thevos et al., 2000). A randomized trial in Zambia, Madagascar, and Kenya demonstrated the effectiveness of household SWS promotion interventions (Quick, 2003). 4.6. Handwashing Diarrheal diseases and acute respiratory infections are two of the leading causes of mortality among children under five worldwide. Handwashing promotion is the most cost-effective public
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health intervention available and has the potential to prevent 50 percent of both diarrheal diseases and ARIs (Luby et al., 2005; Cogswell and Jensen, 2008). Programme Saniya, launched as part of a randomized observational study in Burkina Faso, aimed to reduce the prevalence of diarrheal disease by promoting correct handwashing techniques and proper stool disposal. For three years, researchers implemented a combination of mass media campaigns, street theatre, house-to-house visits, and a hygiene-focused school curriculum. Post-intervention surveys and observations revealed a significant increase in the occurrence of handwashing with soap (Curtis et al., 2001). Another example of the effectiveness of social marketing in handwashing promotion interventions is a study conducted in a rural area of northeast Thailand, in which researchers used various social marketing techniques (songs, print media, theatre) along with workshops for health workers and students to promote dishwashing and handwashing. Researchers also eliminated literacy barriers by including illustrations in all print media. The results of the randomized controlled study showed a 39 percent decrease in the incidence of diarrheal disease among children under 5 years. When subjects were asked to detail messages learned from various sources, they reported retaining the most information from print media, namely stickers and leaflets (Ahmed et al., 1993). In several squatter settlements located in Karachi, Pakistan, researchers conducted a randomized control trial on the effect of community health promoters on the incidence of diarrhea, impetigo, and pneumonia. One treatment group received antibacterial soap and the other received plain soap. For one year, community outreach workers made weekly visits to households in both treatment groups to promote proper hand washing techniques. There was no significant difference between the two treatment groups, but treatment households had 53 percent lower incidence of diarrhea, 36 percent lower incidence of impetigo, and 50 percent lower incidence of pneumonia than households in the control group (Luby et al., 2005). 4.7. Oral rehydration therapy Oral rehydration therapy (ORT) is the most cost-effective method for lowering childhood mortality during a severe episode of diarrhea (UNICEF, 2008). Social marketing saves lives by enabling organizations to reach and educate large segments of the population simultaneously. In India, researchers compared mothers who had seen television spots about ORT to those exposed to ORT through other means. They found that the mothers who learned about ORT through television spots were significantly more likely to correctly apply the knowledge in daily life. Social marketing can also enhance the effectiveness of a private sector approach to increase the use of ORT. In Kenya, public clinics provided oral rehydration packets free-of-charge, while private pharmacies sold flavored packets. This approach was coupled with a mass media campaign educating the public on the availability and proper use of ORT, which resulted in a significant increase in ORT sales through both clinics and pharmacies and an increase in the percentage of residents correctly utilizing the packets (Kenya et al., 1990). 4.8. General hygiene education The United States Agency for International Development, Environmental Health Project, UNICEF, and Water Supply & Sanitation Collaborative Council designed the Hygiene Improvement Framework, outlining the necessary components of a successful diarrhea prevention program (UNICEF, 2010). One of the three pillars of a
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diarrhea prevention program is hygiene promotion, which includes social mobilization, marketing, community participation, and raising awareness, all of which can be achieved through the “four P’s” of an effective social marketing campaign (Kleinau et al., 2004). Organizations can use social marketing in a variety of ways to promote proper hygiene and lower the prevalence of diarrhea. In rural Bangladesh, village leaders implemented the “Clean Life” campaign, a community-based hygiene intervention focusing on ground sanitation, personal hygiene, and food hygiene. The quasiexperimental study found improved growth and a reduction in the number of undernourished infants (Ahmed et al., 1993).
Future research should focus on the mechanisms of behavior change. While many programs were successful, it is unclear from this review what behavioral mediators were responsible. For example, many programs attempted to change social norms. Are strategies aimed at changing personal hygiene practices by promoting the norm that such behaviors are widespread among peers and socially approved most effective? Future studies need to focus squarely on these questions in order to identify best practices in water and sanitation social marketing and diffuse the most effective behavior change strategies. Financial competing interests
5. Conclusion The goal of a published body of literature is to advance the field by providing insight and direction to future research. As such, we identified a number of characteristics that are important to the field of social marketing relating to water and sanitation behaviors and products, and should be included in future published studies of such public health efforts. The current literature represents a broad span of quality, with most studies providing clear reports of the strategy and actions taken to develop and evaluate the marketing effort, but others providing only minimal information in a few of the identified domains. We addressed the specific aims of this systematic review set forth at the outset. First, we identified the types of activities that water and sanitation social marketing interventions efforts have used. There have been widespread efforts to change sanitation practices ranging from personal hygiene to building sanitation infrastructure in villages. Programs have used both individual behavior change and infrastructure improvement schemes to create an environment in which behavior change can occur. Second, we described the marketing mix used in social marketing in this area. Overall, there is widespread use of each of the 4 Ps of marketing, with some interventions not having an explicitly reported ‘price’ strategy. This is a strength of the programs reviewed, and it is noteworthy that many use an explicit branding strategy to build long-term relationship with product consumers, such as in ORT and SWS. Third, we identified the research evaluation methods, design, and reported impacts from the social marketing efforts. Evaluations were generally well designed under challenging local circumstances and there is consistent evidence of improvements in behavioral mediators (ie, knowledge, attitudes, beliefs targeted by the social marketing). Virtually all interventions reported on such mediators. Examples included intentions to use water and sanitation products, self-efficacy to use them following interventions such as motivational interviewing and training, and social norms that use of such products was widespread and a preferred practice in the community post-intervention. Evidence for behavior change is mixed, with successes clustered in SWS programs. This review has some limitations. First, this study shared the well known limitations in reviews of social marketing, which stem mainly from variable use of keywords and descriptors for interventions (McDermott et al., 2005). Not all relevant published studies may have described themselves using social marketing terms, and thus may have been missed by this review. However, we used a variety of search terms and employed expert inputs and knowledge of the field to address this concern. Second, we identified relatively few sanitation related social marketing interventions. This may be related to the first limitation, and the possibility that social marketing aimed at sanitation appears mainly in the gray literature. However, there is a need to promote these studies and publication of sanitation social marketing interventions.
The authors certify that they have received no financial support of any kind related to preparation of this manuscript. The authors certify that they hold no stocks or shares in any such organization. The authors certify that they have not applied for any patents or received any reimbursement from organizations holding patents related to this manuscript. The authors certify that they have no other competing financial interests. Non-financial competing interests The authors certify that they have no competing non-financial interests related to this manuscript. Author’s contributions WDE co-conceived the study, directed the literature search, reviewed articles, and wrote sections of the manuscript. SKP coconceived the study, reviewed articles, and edited sections of the manuscript. SY searched the literature, created the tables, edited sections of the manuscript and compiled references. JB assisted in literature searching and edited sections of the manuscript. SR assisted in literature searching and edited sections of the manuscript. JWB assisted with literature searching and edited sections of the manuscript. All authors read and approved the final manuscript. Acknowledgment The authors gratefully acknowledge their institutions, The George Washington University and Duke University, for their support of this publication effort. While no financial support was provided and the institutions played no role in the manuscript preparation, both institutions encouraged the authors to pursue this project and allowed the use of institutional facilities to support the work. References Ahmed, N.U., Zeitlin, M.F., Beiser, A.S., Super, C.M., Gershoff, S.N., 1993. A longitudinal study of the impact of behavioural change intervention on cleanliness, diarrhoeal morbidity and growth of children in rural Bangladesh. Social Science & Medicine 37 (2), 159e171. Borden, N., 1964. The concept of the marketing mix. Journal of Advertising Research 4 (6), 2e7. Cogswell, L., Jensen, L., 2008. Guidelines for Assessing the Enabling Environment Conditions for Large Scale, Effective and Sustainable Handwashing with Soap Projects. World Bank. Retrieved on 23 August 2013 from. https://www.wsp.org/ wsp/sites/wsp.org/files/publications/EEA_Guidance_HW.pdf. Curtis, V., Kanki, B., Cousens, S., Biallo, I., Kpozehouen, A., Sangaré, M., Nikiema, M., 2001. Evidence of behaviour change following a hygiene promotion programme in Burkina Faso. Bulletin of the World Health Organization 79 (6), 518e527. Developing World: 2013. A Handbook for Implementing Household-based Water Treatment and Safe Storage Projects. Atlanta, GA: Author. Retrieved on 23 August 2013 from. http://www.cdc.gov/safewater/manual/sws_manual.pdf Devine, J., 2008. Sanitation Marketing. Retrieved on 23 August 2013 from: http:// www.wsp.org/wsp/sites/wsp.org/files/Brighton_Jacqueline_Devine_PPT.pdf.
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Migele, J., Ombeki, S., Ayalo, M., Biggerstaff, M., Quick, R., 2007. Diarrhea prevention in a Kenyan school through the use of a simple safe water and hygiene intervention. American Journal of Tropical Medicine and Hygiene 76 (2), 351e353. Nanan, D., White, F., Azam, I., Afsar, H., Hozhabri, S., 2003. Evaluation of a water, sanitation, and hygiene education intervention on diarrhoea in northern Pakistan. Bulletin of the World Health Organization 81 (3), 160e165. Onyango-Ouma, W., Aagaard, H.J., Jensen, B.B., 2005. The potential of schoolchildren as health change agents in rural western Kenya. Social Science & Medicine 61 (8), 1711e1722. Parker, A.A., Stephenson, R., Riley, P.L., Ombeki, W., Komolleh, C., Sibley, L., Quick, R.E., 2006. Sustained high levels of stored drinking water treatment and retention of hand-washing knowledge in rural Kenyan households following a clinic-based intervention. Epidemiology of Infection 134 (5), 1029e1036. Pattanayak, S.K., Yang, J.C., Dickinson, K.L., Poulos, C., Patil, S.R., Mallick, R.K., Praharaj, P., 2009. Shame or subsidy revisited: social mobilization for sanitation in Orissa, India. Bulletin of the World Health Organization 87 (8), 580e587. Pinfold, J.V., 1999. Analysis of different communication channels for promoting hygiene behavior. Health Education Research 14 (5), 629e639. Pinfold, J.V., Horan, N.J., 1996. Measuring the effect of a hygiene behavior intervention by indicators of behaviour and diarrhoeal disease. Transactions of the Royal Society of Tropical Medicine and Hygiene 90 (4), 366e371. Quick, R., 2003. Changing community behavior: experience from three African countries. International Journal of Environmental Health Research 13 (S1), S115eS121. Quick, R.E., Kimura, A., Thevos, A., Tembo, M., Shamputa, I., Hutwagner, L., et al., 2002. Diarrhea prevention through household-level water disinfection and safe storage in Zambia. American Journal of Tropical Medicine and Hygiene 66 (5), 584e589. Quick, R.E., Venczel, L.V., Mintz, E.D., Soleto, L., Aparicio, J., Gironaz, M., Tauxe, R.V., 1999. Diarrhoea prevention in Bolivia through point-of-use water treatment and safe storage: a promising new strategy. Epidemiology and Infection 122 (1), 83e90. Snyder, L.B., Hamilton, M.A., Mitchell, E.W., Kiwanuka-Tondo, J., Fleming-Milici, F., Proctor, D., 2004. A meta-analysis of the effect of mediated health communication campaigns on behavior change in the United States. Journal of Health Communication 9 (Suppl. 1), 71e96. Stockman, L.J., Fischer, T.K., Deming, M., Ngwira, B., Bowie, C., Cunliffe, N., Quick, R.E., 2007. Point-of-use water treatment and use among mothers in Malawi. Emerging Infectious Disease 13 (7), 1077e1080. Thevos, A.K., Kaona, F.A., Siajunza, M.T., Quick, R.E., 2000. Adoption of safe water behaviors in Zambia: comparing educational and motivational approaches. Education for Health 13 (3), 366e376. Thevos, A.K., Olsen, S.J., Rangel, J.M., Kaona, F.A.D., Tembo, M., Quick, R.E., 2003. Social marketing and motivational interviewing as community interventions for safe water behaviors: follow-up surveys in Zambia. International Quarterly of Community Health Education 21 (1), 51e65. UNICEF, 2008. The State of the World’s Children 2008. Retrieved on 23 August 2013 from: http://www.unicef.org/publications/files/The_State_of_the_Worlds_ Children_2008.pdf. pp. 1e9. UNICEF, 2010. Social Marketing Approaches to Child Survival. Retrieved from: http:// www.unicef.org/supply/files/11_Angus_Spiers_-_PSI_-_Social_Marketing_ Approaches_to_Child_Survival.pdf. Wood, S., Foster, J., Kols, A., 2011. Understanding why women adopt and sustain home water treatment: Insights from the Malawi antenatal care program. Social Science & Medicine, 634e642. http://dx.doi.org/10.1016/j.socscimed.2011.09.018. Yeager, B.A., Huttly, S.R., Bartolini, R., Marin, M., Lanata, C.F., 2002. An intervention for the promotion of hygienic feces disposal behaviors in a shanty town of Lima, Peru. Health Education Research 17 (6), 761e773.
Contents lists available at ScienceDirect
Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed
Review
Social marketing of water and sanitation products: A systematic review of peer-reviewed literature W.D. Evans a, *, S.K. Pattanayak b, S. Young a, J. Buszin c, S. Rai b, Jasmine Wallace Bihm a a
The George Washington University, 2175 K Street, NW, Suite 700, Washington, DC 20037, USA Duke University, Sanford Institute of Public Policy, 126 Rubenstein Hall, Durham, NC 27708, USA c Population Services International, 1120 19th Street, NW, Washington, DC 20036, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 26 August 2013 Received in revised form 23 January 2014 Accepted 12 March 2014 Available online 21 March 2014
Like commercial marketing, social marketing uses the 4 “Ps” and seeks exchange of value between the marketer and consumer. Behaviors such as handwashing, and products such as those for oral rehydration treatment (ORT), can be marketed like commercial products in developing countries. Although social marketing in these areas is growing, there has been no systematic review of the current state of practice, research and evaluation. We searched the literature for published peer-reviewed studies available through major online publication databases. We identified manuscripts in the health, social science, and business literature on social marketing that used at least one of the 4 Ps of marketing and had a behavioral objective targeting the behaviors or products related to improving water and sanitation. We developed formalized decision rules and applied them in identifying articles for review. We initially identified 117 articles and reviewed a final set of 32 that met our criteria. Social marketing is a widespread strategy. Marketing efforts have created high levels of awareness of health threats and solutions, including behavior change and socially marketed products. There is widespread use of the 4 Ps of marketing, with price interventions being the least common. Evaluations show consistent improvements in behavioral mediators but mixed results in behavior change. Interventions have successfully used social marketing following widely recommended strategies. Future evaluations need to focus on mediators that explain successful behavior change in order to identify best practices and improve future programs. More rigorous evaluations including quasiexperimental designs and randomized trials are needed. More consistent reporting of evaluation results that permits meta-analysis of effects is needed. Ó 2014 Elsevier Ltd. All rights reserved.
Keywords: Social marketing Health promotion Behavior change Water Sanitation Diarrheal disease
1. Introduction At its core, marketing is about an exchange of value between the marketer and consumer. If the marketer can promote a product or service to make the consumer perceive sufficient value, the consumer is more likely to purchase it. The marketer’s objective is to create value for consumers and thereby financial benefit for the marketer or her clients. Social marketers use the same powerful idea in a different way e not to sell products and services for the benefit of the marketer but to promote socially beneficial causes
* Corresponding author. E-mail addresses: [email protected] (W.D. Evans), subhrendu.pattanayak@ duke.edu (S.K. Pattanayak), [email protected] (S. Young), [email protected] (J. Buszin), [email protected] (S. Rai), [email protected] (J.W. Bihm). http://dx.doi.org/10.1016/j.socscimed.2014.03.011 0277-9536/Ó 2014 Elsevier Ltd. All rights reserved.
and behaviors for the benefit of the audience (Hastings, 2007). A growing body of evidence shows that marketing is highly effective in this arena as well (Evans et al., 2008). Like commercial marketing, social marketing uses the basic principles of the “marketing mix”, or 4 “Ps” of place, price, product, and promotion (Borden, 1964; Kotler and Lee, 2008). Just as a brand of toothpaste can be effectively marketed by making it available to consumers in convenient locations, pricing it right relative to competitors, endowing it with attractive perceived benefits, and advertising it in persuasive ways with sufficient frequency, behaviors such as handwashing and treatment products such as those for oral rehydration salts (ORS) can also be marketed. In the case of handwashing, we may need to think differently about factors such as ‘price’ (time and effort, or convenience) and ‘product’ (the social or functional benefits gained from the behavior) but the basic approach is the same (Evans and Hastings, 2008).
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Recently, there has been growth in social marketing to promote healthy drinking water and sanitation practices, as well as treatments to prevent water-related illnesses such as diarrheal disease (Devine, 2008; Freeman et al., 2009). However, to date there have been no known efforts to systematically review and assess the extent, nature, and evidence of effectiveness for social marketing in global water and sanitation programs. The purpose of this paper is to systematically review the published literature on this topic and evaluate the state of practice and evidence in the field. Specifically, we sought to identify 1) the presence or absence of specific social marketing activities in each intervention, 2) the presence or absence of each of the 4 Ps of marketing in the interventions, and 3) the outcome of the evaluation conducted in these social marketing interventions. Based on results of this review, we discuss the need for interventions that incorporate more Ps, more outcomes research, and more research on the effectiveness of specific intervention strategies and combinations of the 4 Ps. 2. Methods We conducted a systematic search of the published, peerreviewed literature using all relevant major online research literature databases (specified below) and following widely accepted methods for systematic review (Higgins and Green, 2011). We note that social marketing and interventions focused on water and sanitation are also widely represented in unpublished reports and other ‘gray’ literature. However, we focused on peer-reviewed literature in order to ensure quality of evidence and consistency with accepted systematic review practices. We identified as relevant any manuscripts in the published health, social science, and business literature that used at least one of the 4 Ps of marketing, had a behavioral objective targeting water and sanitation related behaviors, and had a health objective targeting diarrheal disease. We based the review methodology in part on methodologies from a previous review of branded social marketing campaigns conducted by the lead author (Evans et al., 2008). Specifically, we searched the following health, social science, and business databases: PubMed, PsycINFO, Web of Science (includes Science Citation Index Expanded, Social Sciences Citation Index, and Arts & Humanities Citation Index), Communication & Mass Media Complete, Academic Search Premier, Business Source Premier, CINAHL, Health Source: Nursing/Academic Edition, and Health Source: Consumer Edition. Search terms included the following: Diarrhea/Diarrhoea, Hygiene, Water, Sanitation, Social Marketing, Health Promotion, Health Communication, Community Intervention, Community Health, Behavior Change. We selected these terms based on the authors’ experiences in the field and conducting previous reviews, and in consultation with a medical research librarian. For completeness, we also searched literature known to the authors, including publications on water and sanitation intervention studies in the developing world. In particular, the bibliographies of two recent meta-analyses on social marketing and mass media intervention were reviewed and potential citations screened following the methods described (Snyder et al., 2004; Grilli et al., 2002). We searched all sources listed above in the date range of 1991e June 2013). Based on this process, we created a database of all 352 unduplicated articles on social marketing interventions regarding diarrhea and water or sanitation. We immediately excluded 235 articles regarding ‘breastfeeding and diarrhea’, ‘zinc supplementation and diarrhea’, and articles that did not include an intervention of any kind. After this initial phase, we identified 117 articles.
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Next, we reviewed the articles based on our specific criteria for inclusion in study. Namely, we screened them for reports on interventions that: 1) were original research (not review papers, meta-analyses, or commentaries); 2) utilized some form of social marketing principles (i.e., reported on use of 1 or more of the four Ps); 3) targeted behavior relating to water or sanitation; and 4) targeted diarrhea prevalence and/or morbidity as a health objective. We also screened to ensure the articles included specific reports of evaluation or implementation of social marketing activities, defined as coordinated efforts to promote, distribute, or use pricing strategies to encourage adoption of various products aimed primarily at diarrheal disease prevention. Based on this indepth screening process, we excluded 85 articles and identified 32 articles for inclusion in the study. Fig. 1 summarizes the review process. Note that due to the diverse nature of the literature on social marketing interventions in this area, and the varying methods of reporting outcomes, we chose not to attempt a meta-analysis of effects of reviewed interventions on behavior. Rather the purpose of this paper is to describe the nature of the interventions and literature, hopefully promoting more uniform reporting of outcomes in future. Once the review sample of articles was identified, the first two authors individually read each of the articles in-depth and coded them for specific content reported in the results section. The results of all reviews were compiled and discussed by the reviewers. Potential sources of differences in assumptions and approach in coding articles were identified and discussed. A consensus was reached about coding, and common procedures adopted where discrepancies had been identified. 3. Results Table 1 provides a summary of basic information gleaned from each water and sanitation article reviewed. The articles dealt with interventions relating to household water treatment, handwashing, safe disposal of feces and personal hygiene. The studies covered 14 developing countries, mostly in South Asia and Africa. The interventions used a wide range of health communication and social marketing strategies, including mass media, interpersonal communication (IPC), community outreach and visits to households by health workers. New and social media, while rapidly growing forms of communication, were not identified as strategies in any of the reviewed papers. High levels of awareness of the promoted health messages were reported. Table 2 provides a summary of the topic areas that were the focus of social marketing interventions. Most interventions focused on behaviors practiced inside the home, such as handwashing, point-of-use water treatment, dishwashing and various hygiene practices. Several interventions incorporated more than one desired behavior, such as appropriate water storage in combination with point-of-use water treatment. Table 3 provides a summary of the social marketing development described in the water and sanitation articles reviewed. In some cases, studies described specific scientific theories used in the development of the social marketing effort used. Psychology and communication theories were the most commonly used theories, found in 26% and 23% of the studies reviewed, respectively. Some of the articles described intervention efforts based in formative research such as interviews and focus groups. Examination of the studies in terms of the use of the 4 Ps of marketing revealed a majority using each of the four marketing techniques. Almost all articles (96.8%) used “product” and “promotion” marketing techniques. The product P was represented by 1) safe water treatment products and 2) behavioral product approaches in which hand-washing and
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Fig. 1. PRISMA diagram of systematic review process.
sanitation behaviors were marketed as having social and functional benefits. The price P was only explicitly addressed in the safe water treatment product interventions, with subsidies to reduce costs of the marketed systems used to encourage purchase and use. The place P was represented by 1) community-based sales approaches, 2) home visit approaches, and 3) health clinics to simplify distribution. The promotion P was represented by mass advertising, community outreach, use of branded gear such as t-shirts, and promotion by health care providers at clinics. Community outreach was a heavily utilized marketing channel present in 96.8% of the intervention efforts. Table 4 provides a summary of the study design and outcomes in the water and sanitation articles reviewed. Most of the articles reviewed described studies with an observational design; the remaining studies were equally split between experimental and quasi-experimental designs. Almost all articles reported on the study sample size and sample characteristics. Multivariate analysis was used to report statistics in over half of the studies. Most of the studies (75%) aimed to assess behavioral objectives and clearly stated these objectives. Almost all of these studies reported product/behavior awareness or reactions to the interventions. 4. Discussion Tables 1e4 outline various aspects of the studies that used social marketing in water and sanitation interventions. We analyzed
activities that each of the interventions used and examined the extent to which they incorporated the four Ps of social marketing. 4.1. Product Over a third of the studies reviewed used the Safe Water System, which promotes point-of-use water treatment (specifically a sodium hypochlorite solution), safe storage and behavior change. The sodium hypochlorite solution is marketed under different names Sur’ Eau in Madagascar, Klorin in Kenya, WaterGuard in Malawi e but is always locally produced and sold. The use of a distinctive brand name and logo echoes the marketing techniques used by the private sector to ensure product differentiation. However not every intervention employed such a strategy. In Dongre et al. (2008), for example, unbranded faucet-fitted earthen vessels were sold to consumers in India; in Nanan et al. (2003) and Pattanayak et al. (2009), the programs provided unmarked latrines to rural households in Pakistan and India. Branding can also extend to the entire campaign. In Ahmed et al. (1993), hygiene behaviors in Bangladesh were marketed under a “Clean Life campaign”. The product, in both the Safe Water System and other interventions, is in some cases behavioral or attitudinal. Every reviewed study also had as a product the health gains that arose from a hygiene-related behavior like handwashing, water treatment or safe disposal of feces.
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Table 1 Overview of studies in this review. Topic area
Citation
Public health campaign
Research design
Location
Safe water system Safe water system
Dunston et al. (2001) Makutsa et al. (2001)
Paired study; randomized Non-experimental
Madagascar Kenya
Safe water system Point-of-use water treatment
Quick (2003). Parker et al. (2006)
Safe Water System (Sûr’Eau) Water, Sanitation, and Education for Health (WASEH) Project Safe Water System (SWS) Safe Water System (SWS)
Zambia, Madagascar, Kenya Kenya
Handwashing; safe disposal of feces Handwashing; dishwashing
Curtis et al. (2001)
Saniya
Pinfold (1999)
Faucet-fitted earthen vessels; point-of-use water treatment Safe Water System
Dongre et al. (2008)
Social marketing e (posters and curriculum within schools, leaflets, stickers, handwashing containers, posters Community-Led Initiatives for Child Survival (CLICS) program
Experimental; field trials Non-experimental; Paired Study Observational study; randomized Experimental; microbiological indicators (fingertip contamination Quasi-experimental
India
Quasi-experimental
Kenya
Handwashing; point-of-use water treatment; use of local vessels Handwashing; point-of-use water treatment Handwashing
Luby et al. (2004a, b)
Quasi-experimental
Pakistan
Cluster randomized control
Pakistan
Luby et al. (2004a, b)
Children’s books, notebooks, pens and pencils The Karachi Soap Health Study
Pakistan
Handwashing
Luby et al. (2005)
The Karachi Soap Health Study
Hygiene practices; infrastructure Hygiene practices
Nanan et al. (2003)
Water and Sanitation Extension Programme (WASEP) project Participatory health education with students; peer training among students Social marketing techniques to promote dishwashing and hand washing Point-of-use water disinfection; safe storage; community education; weekly visits by community health workers Water treatment with bleach, safe storage, and behavior-change communications Safe Water System, “Waterguard” Safe Water System, “Clorin” Safe Water System, “Clorin” Safe Water System, “Clorin” Promotion through nurses at health clinics e use of IPC, video presentations and leaflets Capacity building and empowerment School-based water, sanitation, and hygiene (WASH) intervention “Waterguard”
Cluster randomized controlled trial Cluster randomized controlled trial Case Control
Pakistan
Quasi-experimental
Kenya
Quasi-experimental
Thailand
Quasi-experimental
Bolivia
Observational
Kenya
Observational Experimental Experimental Experimental Quasi-experimental
Malawi Zambia Zambia Zambia Peru
Repeat cross-sectional Cluster randomized trial
Kenya Kenya
Experimental
Kenya
Experimental
Nepal
Observational Observational Experimental Experimental Experimental Retrospective ecological study
Australia Malawi Guatemala Uganda Zambia Kenya
Handwashing; dishwashing Point-of-use water treatment; safe storage
Garrett et al. (2008)
Luby et al. (2006)
Onyango-Oumaa et al. (2005) Pinfold and Horan (1996) Quick et al. (1999)
Safe water system
Migele et al. (2007)
Safe water system Safe Water System Safe Water System Safe Water System Feces disposal; appropriate places for defacating
Stockman et al. (2007) Thevos et al. (2003) Thevos (2000) Thevos (2000) Yeager et al. (2002)
Hygiene; sanitation Hand washing; water treatment; latrines Hand hygiene; drinking water treatment and storage Zinc-promotion
Kariuki et al. (2012) Greene et al. (2012)
Handwashing Water treatment Water treatment Water treatment and storage Water treatment and storage Safe water system
McDonald et al. (2011) Wood et al. (2012) Luby et al. (2008) Lule et al. (2005) Quick et al. (2002) John et al. (2007)
Ryman et al. (2012) Wang et al. (2011)
Water, Sanitation, and Education for Health (WASEH) Project Home-based intervention
Social Marketing Plus for Diarrhoeal Disease Control: Point of Use Water Disinfection and Zinc Treatment (POUZN) project “No Germs on Me” “Waterguard” Marketing of flocculant-disinfectant Safe water system Safe water system Safe water system
4.2. Place Place in social marketing refers to the distribution channels and outlets through which tangible products are made available to consumers. In the case of health-related behaviors, place could also mean the location where the consumer performs the desired behavior, or accesses information about the product. Where the interventions surveyed involved the transactional exchange of a tangible product, the programs tried to facilitate availability and easy access by utilizing local resources.
Burkina Faso Thailand
Pakistan
In Madagascar, for example, community-based sales agents were trained to provide the sodium hypocholorite solution (Dunston et al., 2001). In Karachi, Pakistan, fieldworkers visited households to distribute soaps for handwashing (Luby et al., 2005), while lidded storage vessels were distributed along with water treatment solutions to households in Nicaragua (Macy and Quick, 1998). Programs also used home visits to promote health related behaviors. Volunteers in Burkina Faso trained volunteers to conduct monthly house-to-house visits to educate households about the
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Table 2 Topic area (n ¼ 32).a
Table 4 Study design and outcomes (n ¼ 32).
Variables
Frequency
%
Variables
Safe water system Point-of-use water treatment Handwashing Dishwashing Improved water supply Use of local vessels Infrastructure Appropriate places for defecating/Safe disposal of feces Ground sanitation Hygiene practices Latrines Safe storage
10 12 9 2 1 2 1 3 1 3 2 4
31.3 37.5 28.1 6.3 3.1 6.3 3.1 9.4 3.1 9.5 6.3 12.5
Research design Experiment Quasi-experiment Observational study Sample size reported Sample characteristics described Response ¼ follow-up rate reported Statistics reported Descriptive Multivariate analysis (ANOVA ¼ regression) Path analysis None Reported Objectives clearly stated Product/behavior awareness or reactions Pre-behavioral outcomes Behavioral outcomes Effects reported Product/behavior awareness or reactions Pre-behavioral outcomes Behavioral outcomes Estimate of precision reported
a
Several articles addressed multiple topics.
benefits of handwashing and safe disposal of feces (Curtis et al., 2001). Where the intervention involved performances or the use of print or visual media, public spaces in the community were also utilized. In northeastern Thailand, for instance songs about hygiene messages were broadcast through village loudspeakers (Pinfold and Horan, 1996). Researchers used weekly prayer meetings at local mosques in rural Bangladesh to talk about cleanliness as a common goal (Ahmed et al., 1993). Targeted interventions also focused on specific groups. In a study in western Kenya, for example, health education was given to schoolchildren in grades three and five using drawings, role-play, songs and poems (Onyango-Ouma et al., 2005). 4.3. Price Price in social marketing could refer to the provision of monetary subsidies (about whose effectiveness there is considerable disagreement) or the costs of time and effort that individuals and households have to bear in adopting the intervention. For the purposes of this paper, however, we focus on monetary subsidies/ incentives. In interventions that used the Safe Water System, household water treatment solutions were sold at subsidized rates, typically a Table 3 Social marketing development (n ¼ 32). Variables Scientific theory Communication Marketing Psychology Other Formative research Focus groups Interviews Other Marketing P’s Product Price Place Promotion Marketing channels Paid mass media Unpaid mass media Earned media Community outreach Community mobilization Mobile phones Social media (not Mobile) Other marketing techniques Audience segmentation Message tailoring Other
Frequency
%
7 2 8 1
21.9 6.3 25.0 3.1
10 9 2
31.3 28.1 6.3
31 20 26 31
96.9 62.5 81.3 96.9
13 4 0 31 19 0 0
40.6 12.5 0.0 96.9 59.4 0.0 0.0
16 3 0
50.0 9.4 0.0
Frequency
%
9 9 14 30 26 12
28.1 28.1 43.8 93.8 80.6 38.7
10 18 1 2
31.3 56.3 3.1 6.3
18 17 24
56.3 53.1 75.0
28 12 27 24
87.5 37.5 84.4 75.0
small fraction of the market price. In Madagascar, for instance, sodium hypocholorite solution was sold at 30 cents for a 500 ml bottle (Dunston et al., 2001), while in western Kenya, the price was 33 cents a bottle (Makutsa et al., 2001; Garrett et al., 2008). In Wardha, India, a 50 ml bottle was sold for 30 cents, along with an earthen vessel fitted with a plastic faucet (Dongre et al., 2008). Similarly, in Zambia, water vessels were supplied at subsidized rates (Thevos et al., 2003). Water treatment solutions were also sold at reduced prices to wholesalers and retailers to stimulate sales (Makutsa et al., 2001). In addition, health workers also sometimes received small commissions as incentives (Garrett et al., 2008). Where the intervention took the form of investments in sanitation infrastructure, households were often asked to bear part of the costs of construction. For instance, CARE Kenya paid for 40% of the costs for providing new latrines in rural communities, but households were expected to pay the remaining 60%, and also provide labor for the latrine construction. Similarly, in a community-led sanitation intervention in Orissa, India, households below the poverty line had to pay 15% of the cost of a new latrine, while other households paid the entire cost (Pattanayak et al., 2009). Another solution, called WaterGuard, was initially distributed at low cost and later provided freely at antenatal women in order to overcome cost barriers (Wood et al., 2011). 4.4. Promotion Promotion is perhaps the most visible aspect of social marketing. It aims to generate demand for the product by imparting information and changing attitudes. Most of the water and sanitation intervention surveyed used extensive promotion techniques. One common strategy e used in interventions in Burkina Faso, Pakistan, Uganda and Bolivia e was to train local health workers/volunteers to impart hygiene education through household visits. Another strategy was to organize neighborhood meetings to promote awareness of hygiene behaviors. For example, in Wardha, India, community-based village co-ordination committees were formed to act as go-betweens between households and program workers (Dongre et al., 2008). Some studies focused on particular spaces of interaction, like clinics and schools. For instance, in Homa Bay, Kenya, nurses at a maternal and child health clinic were trained to communicate
W.D. Evans et al. / Social Science & Medicine 110 (2014) 18e25
information about water chlorination to their clients (Parker et al., 2006). Schoolchildren too can sometimes act as health behavior change agents. In Bondo, western Kenya, schoolchildren underwent participatory health communication training, where they learnt about hygienic behaviors through songs, poems and drawings (Onyango-Ouma et al., 2005). Print and electronic media were used in several studies to disseminate hygiene-related information. Advertisements on radio, television and in newspapers, pamphlets and signs on buses, walls and billboards were just some of the techniques used. Some interventions used community-related activities to get the message of hygiene out. In Nyanza, Kenya, program workers organized soccer tournaments and Klorin quizzes to spread awareness about their product (Makutsa et al., 2001). In Thailand, comic books and T-shirts were developed to support program activities (Pinfold, 1999). 4.5. Design and impacts of interventions that employ social marketing: water treatment at the household level In the 1990s, The Centers for Disease Control and Prevention (CDC) and the Pan American Health Association (PAHO) designed the “Safe Water System,” an intervention using point-of-use treatment, proper storage, and behavior change to improve water safety in developing countries. The behavior change component of the intervention employs media campaigns, community mobilization, and interpersonal communication techniques to increase the connection made between water quality and disease (Centers for Disease Control and Prevention, 2013). Organizations such as CARE International and Population Services International (PSI) have used the Safe Water System (SWS) framework to promote household-level water treatment in nineteen countries across five continents. Participating organizations have often grounded the intervention, tailoring the social marketing component to fit the particular needs of each target community. For example, in Madagascar, CARE and PSI used branding and media campaigns in conjunction with community mobilization in a randomized study to promote the use of the point-of-use treatment system and increased sales from 76,000 bottles in March 2000 to 250,000 bottles in December of the same year (Dunston et al., 2001). CARE also implemented the SWS intervention in Western Kenya and used social marketing and motivational interviewing combined with subsidized prices to promote home water treatment and safe storage. A non-experimental study found that the project resulted in adoption rates of 33.5% for chemical water treatment and 18.5% for clay pots modified for safe water storage (Makutsa et al., 2001). When CARE used the SWS intervention in southern Kenya in another non-experimental study, they grounded the intervention to the target community by incorporating social marketing with a nurse training program focused on the six steps of proper handwashing. One year later, 71% of clients of the clinic had chlorine residuals in their drinking water and 34% were observed using proper hand washing techniques (Parker et al., 2006). Motivational interviewing has been found to be an effective technique for promoting SWS adoption and promotion of behavior changes, as described below, in several African countries (Thevos et al., 2000). A randomized trial in Zambia, Madagascar, and Kenya demonstrated the effectiveness of household SWS promotion interventions (Quick, 2003). 4.6. Handwashing Diarrheal diseases and acute respiratory infections are two of the leading causes of mortality among children under five worldwide. Handwashing promotion is the most cost-effective public
23
health intervention available and has the potential to prevent 50 percent of both diarrheal diseases and ARIs (Luby et al., 2005; Cogswell and Jensen, 2008). Programme Saniya, launched as part of a randomized observational study in Burkina Faso, aimed to reduce the prevalence of diarrheal disease by promoting correct handwashing techniques and proper stool disposal. For three years, researchers implemented a combination of mass media campaigns, street theatre, house-to-house visits, and a hygiene-focused school curriculum. Post-intervention surveys and observations revealed a significant increase in the occurrence of handwashing with soap (Curtis et al., 2001). Another example of the effectiveness of social marketing in handwashing promotion interventions is a study conducted in a rural area of northeast Thailand, in which researchers used various social marketing techniques (songs, print media, theatre) along with workshops for health workers and students to promote dishwashing and handwashing. Researchers also eliminated literacy barriers by including illustrations in all print media. The results of the randomized controlled study showed a 39 percent decrease in the incidence of diarrheal disease among children under 5 years. When subjects were asked to detail messages learned from various sources, they reported retaining the most information from print media, namely stickers and leaflets (Ahmed et al., 1993). In several squatter settlements located in Karachi, Pakistan, researchers conducted a randomized control trial on the effect of community health promoters on the incidence of diarrhea, impetigo, and pneumonia. One treatment group received antibacterial soap and the other received plain soap. For one year, community outreach workers made weekly visits to households in both treatment groups to promote proper hand washing techniques. There was no significant difference between the two treatment groups, but treatment households had 53 percent lower incidence of diarrhea, 36 percent lower incidence of impetigo, and 50 percent lower incidence of pneumonia than households in the control group (Luby et al., 2005). 4.7. Oral rehydration therapy Oral rehydration therapy (ORT) is the most cost-effective method for lowering childhood mortality during a severe episode of diarrhea (UNICEF, 2008). Social marketing saves lives by enabling organizations to reach and educate large segments of the population simultaneously. In India, researchers compared mothers who had seen television spots about ORT to those exposed to ORT through other means. They found that the mothers who learned about ORT through television spots were significantly more likely to correctly apply the knowledge in daily life. Social marketing can also enhance the effectiveness of a private sector approach to increase the use of ORT. In Kenya, public clinics provided oral rehydration packets free-of-charge, while private pharmacies sold flavored packets. This approach was coupled with a mass media campaign educating the public on the availability and proper use of ORT, which resulted in a significant increase in ORT sales through both clinics and pharmacies and an increase in the percentage of residents correctly utilizing the packets (Kenya et al., 1990). 4.8. General hygiene education The United States Agency for International Development, Environmental Health Project, UNICEF, and Water Supply & Sanitation Collaborative Council designed the Hygiene Improvement Framework, outlining the necessary components of a successful diarrhea prevention program (UNICEF, 2010). One of the three pillars of a
24
W.D. Evans et al. / Social Science & Medicine 110 (2014) 18e25
diarrhea prevention program is hygiene promotion, which includes social mobilization, marketing, community participation, and raising awareness, all of which can be achieved through the “four P’s” of an effective social marketing campaign (Kleinau et al., 2004). Organizations can use social marketing in a variety of ways to promote proper hygiene and lower the prevalence of diarrhea. In rural Bangladesh, village leaders implemented the “Clean Life” campaign, a community-based hygiene intervention focusing on ground sanitation, personal hygiene, and food hygiene. The quasiexperimental study found improved growth and a reduction in the number of undernourished infants (Ahmed et al., 1993).
Future research should focus on the mechanisms of behavior change. While many programs were successful, it is unclear from this review what behavioral mediators were responsible. For example, many programs attempted to change social norms. Are strategies aimed at changing personal hygiene practices by promoting the norm that such behaviors are widespread among peers and socially approved most effective? Future studies need to focus squarely on these questions in order to identify best practices in water and sanitation social marketing and diffuse the most effective behavior change strategies. Financial competing interests
5. Conclusion The goal of a published body of literature is to advance the field by providing insight and direction to future research. As such, we identified a number of characteristics that are important to the field of social marketing relating to water and sanitation behaviors and products, and should be included in future published studies of such public health efforts. The current literature represents a broad span of quality, with most studies providing clear reports of the strategy and actions taken to develop and evaluate the marketing effort, but others providing only minimal information in a few of the identified domains. We addressed the specific aims of this systematic review set forth at the outset. First, we identified the types of activities that water and sanitation social marketing interventions efforts have used. There have been widespread efforts to change sanitation practices ranging from personal hygiene to building sanitation infrastructure in villages. Programs have used both individual behavior change and infrastructure improvement schemes to create an environment in which behavior change can occur. Second, we described the marketing mix used in social marketing in this area. Overall, there is widespread use of each of the 4 Ps of marketing, with some interventions not having an explicitly reported ‘price’ strategy. This is a strength of the programs reviewed, and it is noteworthy that many use an explicit branding strategy to build long-term relationship with product consumers, such as in ORT and SWS. Third, we identified the research evaluation methods, design, and reported impacts from the social marketing efforts. Evaluations were generally well designed under challenging local circumstances and there is consistent evidence of improvements in behavioral mediators (ie, knowledge, attitudes, beliefs targeted by the social marketing). Virtually all interventions reported on such mediators. Examples included intentions to use water and sanitation products, self-efficacy to use them following interventions such as motivational interviewing and training, and social norms that use of such products was widespread and a preferred practice in the community post-intervention. Evidence for behavior change is mixed, with successes clustered in SWS programs. This review has some limitations. First, this study shared the well known limitations in reviews of social marketing, which stem mainly from variable use of keywords and descriptors for interventions (McDermott et al., 2005). Not all relevant published studies may have described themselves using social marketing terms, and thus may have been missed by this review. However, we used a variety of search terms and employed expert inputs and knowledge of the field to address this concern. Second, we identified relatively few sanitation related social marketing interventions. This may be related to the first limitation, and the possibility that social marketing aimed at sanitation appears mainly in the gray literature. However, there is a need to promote these studies and publication of sanitation social marketing interventions.
The authors certify that they have received no financial support of any kind related to preparation of this manuscript. The authors certify that they hold no stocks or shares in any such organization. The authors certify that they have not applied for any patents or received any reimbursement from organizations holding patents related to this manuscript. The authors certify that they have no other competing financial interests. Non-financial competing interests The authors certify that they have no competing non-financial interests related to this manuscript. Author’s contributions WDE co-conceived the study, directed the literature search, reviewed articles, and wrote sections of the manuscript. SKP coconceived the study, reviewed articles, and edited sections of the manuscript. SY searched the literature, created the tables, edited sections of the manuscript and compiled references. JB assisted in literature searching and edited sections of the manuscript. SR assisted in literature searching and edited sections of the manuscript. JWB assisted with literature searching and edited sections of the manuscript. All authors read and approved the final manuscript. Acknowledgment The authors gratefully acknowledge their institutions, The George Washington University and Duke University, for their support of this publication effort. While no financial support was provided and the institutions played no role in the manuscript preparation, both institutions encouraged the authors to pursue this project and allowed the use of institutional facilities to support the work. References Ahmed, N.U., Zeitlin, M.F., Beiser, A.S., Super, C.M., Gershoff, S.N., 1993. A longitudinal study of the impact of behavioural change intervention on cleanliness, diarrhoeal morbidity and growth of children in rural Bangladesh. Social Science & Medicine 37 (2), 159e171. Borden, N., 1964. The concept of the marketing mix. Journal of Advertising Research 4 (6), 2e7. Cogswell, L., Jensen, L., 2008. Guidelines for Assessing the Enabling Environment Conditions for Large Scale, Effective and Sustainable Handwashing with Soap Projects. World Bank. Retrieved on 23 August 2013 from. https://www.wsp.org/ wsp/sites/wsp.org/files/publications/EEA_Guidance_HW.pdf. Curtis, V., Kanki, B., Cousens, S., Biallo, I., Kpozehouen, A., Sangaré, M., Nikiema, M., 2001. Evidence of behaviour change following a hygiene promotion programme in Burkina Faso. Bulletin of the World Health Organization 79 (6), 518e527. Developing World: 2013. A Handbook for Implementing Household-based Water Treatment and Safe Storage Projects. Atlanta, GA: Author. Retrieved on 23 August 2013 from. http://www.cdc.gov/safewater/manual/sws_manual.pdf Devine, J., 2008. Sanitation Marketing. Retrieved on 23 August 2013 from: http:// www.wsp.org/wsp/sites/wsp.org/files/Brighton_Jacqueline_Devine_PPT.pdf.
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