Addressing Inequities in Access to Health Products through the Use of Social Marketing, Community Mobilization, and Local Entrepreneurs in Rural Western Kenya
While social marketing can increase uptake of health products in developing countries, providing equitable access is challenging. We conducted a 2-year evaluation of uptake of WaterGuard, insecticide-treated bednets (ITNs), and micronutrient Sprinkles in Western Kenya. Sixty villages were randomly assigned to intervention and comparison groups. Following a baseline survey (BL), a multifaceted intervention comprising social marketing of these products, home visits by product vendors from a local women’s group (Safe Water and AIDS Project, or SWAP), product promotions, and modeling of water treatment and safe storage in was implemented in intervention villages. Comparison villages received only social marketing of WaterGuard and ITNs. We surveyed again at one year (FU1), implemented the intervention in comparison villages, and surveyed again at two years (FU2). At BL, <3% of households had been visited by a SWAP vendor. At FU1, more intervention than comparison households had been visited by a SWAP vendor (39% versus 9%, ), and purchased WaterGuard (14% versus 2%, ), Sprinkles (36% versus 6%, ), or ITNs (3% versus 1%, ) from that vendor. During FU2, 47% and 41% of original intervention and comparison households, respectively, reported ever receiving a SWAP vendor visit ( ); >90% those reported ever purchasing a product from the vendor. WaterGuard ( ) and ITNs ( ) were purchased less frequently by lower-SES than higher-SES households; Sprinkles, the least expensive product, was purchased equally across all quintiles. 1. Introduction In 2005, 1.4 billion people in the developing world lived on less than $1.25 per day [1]. Children living in these regions also experienced the highest global burden of morbidity and mortality from acute respiratory infections, diarrhea, malaria, and malnutrition, and the poorest access to health services and improved water sources [2]. Provision of health products and services in resource-poor countries is a major challenge to governments and aid organizations. Understanding the multiple competing needs of the poor, providing affordable products and services to meet those needs, and mobilizing resources for delivery of products and services, particularly to geographically remote areas, is challenging. Social marketing—broadly described as the combination of education to motivate healthy behaviors and the provision of attractively packaged, affordable products and services to low-income persons [3]—is one tool that has become widely used in recent years to promote health products such as condoms [4–6], insecticide-treated
References
[1]
S. Chen and M. Ravallion, “Developing world is poorer than we thought, but no less successful in the fight against poverty,” World bank Policy Research Working Paper Series, 2008, http://ssrn.com/abstract=1259575.
[2]
WHO, “World Health Statistics 2009,” 2009, http://www.who.int/whosis/whostat/EN_WHS09_Full.pdf.
[3]
PSI, “What is social marketing?” 2006, http://www.psi.org/resources/research-metrics/publications/social-marketing-research-series/what-social-marketing-0.
[4]
D. Meekers, R. Van Rossem, M. Silva, and A. Koleros, “The reach and effect of radio communication campaigns on condom use in Malawi,” Studies in Family Planning, vol. 38, no. 2, pp. 113–120, 2007.
[5]
R. Van Rossem and D. Meekers, “The reach and impact of social marketing and reproductive health communication campaigns in Zambia,” BMC Public Health, vol. 7, article no. 352, 2007.
[6]
M. Versteeg and M. Murray, “Condom use as part of the wider HIV prevention strategy: experiences from communities in the North West Province, South Africa,” Sahara J, vol. 5, no. 2, pp. 83–93, 2008.
[7]
D. P. Mathanga, C. H. Campbell, T. E. Taylor, R. Barlow, and M. L. Wilson, “Socially marketed insecticide-treated nets effectively reduce Plasmodium infection and anaemia among children in urban Malawi,” Tropical Medicine and International Health, vol. 11, no. 9, pp. 1367–1374, 2006.
[8]
S. Agha, R. Van Rossem, G. Stallworthy, and T. Kusanthan, “The impact of a hybrid social marketing intervention on inequities in access, ownership and use of insecticide-treated nets,” Malaria Journal, vol. 6, article no. 13, 2007.
[9]
A. M. Noor, A. A. Amin, W. S. Akhwale, and R. W. Snow, “Increasing coverage and decreasing inequity in insecticide-treated bed net use among rural Kenyan children,” PLoS Medicine, vol. 4, no. 8, article e255, pp. 1341–1348, 2007.
[10]
J. Bernard, G. Mtove, R. Mandike, F. Mtei, C. Maxwell, and H. Reyburn, “Equity and coverage of insecticide-treated bed nets in an area of intense transmission of Plasmodium falciparum in Tanzania,” Malaria Journal, vol. 8, no. 1, article no. 65, 2009.
[11]
W. D. Evans, J. Blitstein, J. C. Hersey, J. Renaud, and A. L. Yaroch, “Systematic review of public health branding,” Journal of Health Communication, vol. 13, no. 8, pp. 721–741, 2008.
[12]
R. Kyama and D. G. McNeil, “Distribution of nets splits malaria fighters,” New York Times, 2007.
[13]
A. Teklehaimanot, J. D. Sachs, and C. Curtis, “Malaria control needs mass distribution of insecticidal bednets,” Lancet, vol. 369, no. 9580, pp. 2143–2146, 2007.
[14]
L. J. Stockman, T. K. Fischer, M. Deming et al., “Point-of-use water treatment and use among mothers in Malawi,” Emerging Infectious Diseases, vol. 13, no. 7, pp. 1077–1080, 2007.
[15]
Kenya National Bureau of Statistics, “N., Kenya and MEASURE DHS, ICF Macro, Calverton, Maryland, USA,” Kenya: DHS, 2008-09, Final Report, 2009.
[16]
M. R. Desai, D. J. Terlouw, A. M. Kwena et al., “Factors associated with hemoglobin concentrations in pre-school children in western Kenya: cross-sectional studies,” American Journal of Tropical Medicine and Hygiene, vol. 72, no. 1, pp. 47–59, 2005.
[17]
M. E. D. Jefferds, L. Ogange, M. Owuor et al., “Formative research exploring acceptability, utilization, and promotion in order to develop a micronutrient powder (Sprinkles) intervention among Luo families in western Kenya,” Food and Nutrition Bulletin, vol. 31, no. 2, supplement, pp. S179–S185, 2010.
[18]
P. S. Suchdev, L. Ruth, A. Obure et al., “Monitoring the marketing, distribution, and use of Sprinkles micronutrient powders in rural western Kenya,” Food and Nutrition Bulletin, vol. 31, no. 2, supplement, pp. S168–S178, 2010.
[19]
M. C. Freeman, R. E. Quick, D. P. Abbott, P. Ogutu, and R. Rheingans, “Increasing equity of access to point-of-use water treatment products through social marketing and entrepreneurship: a case study in western Kenya,” Journal of Water and Health, vol. 7, no. 3, pp. 527–534, 2009.
[20]
P. Makutsa, K. Nzaku, P. Ogutu et al., “Challenges in implementing a point-of-use water quality intervention in rural Kenya,” American Journal of Public Health, vol. 91, no. 10, pp. 1571–1573, 2001.
[21]
R. Quick, “Changing community behaviour: experience from three African countries,” International Journal of Environmental Health Research, vol. 13, supplement 1, pp. S115–S121, 2003.
[22]
G. W. Fegan, A. M. Noor, W. S. Akhwale, S. Cousens, and R. W. Snow, “Effect of expanded insecticide-treated bednet coverage on child survival in rural Kenya: a longitudinal study,” Lancet, vol. 370, no. 9592, pp. 1035–1039, 2007.
[23]
A. M. Noor, J. J. Mutheu, A. J. Tatem, S. I. Hay, and R. W. Snow, “Insecticide-treated net coverage in Africa: mapping progress in 2000–07,” The Lancet, vol. 373, no. 9657, pp. 58–67, 2009.
[24]
D. Filmer and L. H. Pritchett, “Estimating wealth effects without expenditure data—Or tears: an application to educational enrollments in states of India,” Demography, vol. 38, no. 1, pp. 115–132, 2001.
[25]
D. R. Gwatkin, S. Rustein, K. Johnson, R. Pande, A. Wagstaff, and A. Amouzou, “Socio-economic differences in health, nutrition, and population in Kenya,” The World Bank, 2007.
[26]
J. Gregson, S. B. Foerster, R. Orr et al., “System, environmental, and policy changes: using the social-ecological model as a framework for evaluating nutrition education and social marketing programs with low-income audiences,” Journal of Nutrition Education and Behavior, vol. 33, supplement 1, pp. S4–S15, 2001.
[27]
W. D. Evans, “What social marketing can do for you,” British Medical Journal, vol. 332, no. 7551, pp. 1207–1210, 2006.
[28]
L. M. Barat, N. Palmer, S. Basu, E. Worrall, K. Hanson, and A. Mills, “Do malaria control interventions reach the poor? A view through the equity lens,” American Journal of Tropical Medicine and Hygiene, vol. 71, no. 2, supplement, pp. 174–178, 2004.
[29]
A. A. Parker, R. Stephenson, P. L. Riley et al., “Sustained high levels of stored drinking water treatment and retention of hand-washing knowledge in rural Kenyan households following a clinic-based intervention,” Epidemiology and Infection, vol. 134, no. 5, pp. 1029–1036, 2006.
[30]
E. C. Briere, T. K. Ryman, E. Cartwright, et al., “Impact of integration of hygiene kit distribution with routine immunizations on infant vaccine coverage and water treatment and handwashing practices of Kenyan mothers,” Journal of Infectious Diseases, vol. 205, supplement 1, pp. S56–S64, 2012.
[31]
A. N. Sheth, E. T. Russo, M. Menon et al., “Impact of the integration of water treatment and handwashing incentives with antenatal services on hygiene practices of pregnant women in Malawi,” American Journal of Tropical Medicine and Hygiene, vol. 83, no. 6, pp. 1315–1321, 2010.
[32]
O. Onwujekwe, E. F. Malik, S. H. Mustafa, and A. Mnzavaa, “Do malaria preventive interventions reach the poor? Socioeconomic inequities in expenditure on and use of mosquito control tools in Sudan,” Health Policy and Planning, vol. 21, no. 1, pp. 10–16, 2006.
[33]
K. Hanson, T. Marchant, R. Nathan et al., “Household ownership and use of insecticide treated nets among target groups after implementation of a national voucher programme in the United Republic of Tanzania: plausibility study using three annual cross sectional household surveys.,” BMJ, vol. 339, article b2434, 2009.
[34]
F. Ponsar, M. VanHerp, R. Zachariah, et al., “Abolishing user fees for children and pregnant women trebled uptake of malaria-related interventions in Kangaba, Mali,” Health Policy and Planning, vol. 26, supplement 2, pp. ii72–ii83, 2011.
[35]
J. C. Fotso and B. Kuate-Defo, “Socioeconomic inequalities in early childhood malnutrition and morbidity: modification of the household-level effects by the community SES,” Health and Place, vol. 11, no. 3, pp. 205–225, 2005.
