Dr Sanjay Kalra – Consultant Endocrinologist, Bharti Hospital Karnal & Vice President, South Asian Federation of Endocrine Societies emphasises on the use of social marketing tools to improve use of insulin therapy
Data from across the world reflects the increasing prevalence of type II diabetes mellitus, making it clear that diabetes will remain endemic to almost all human societies for generations to come1. However, it cannot be denied that our capability to fight the disease has also seen advancement. Our understanding of the pathophysiology has increased, as has the variety of drugs available to counteract this pathology 2. Advances in monitoring technology, drug development and delivery device have meant that safe and effective pharmacotherapy is now available for the vast majority of people with diabetes.
Hard hitting ground reality
Sadly, the better understanding of the pathophysiology has not translated into visible improvement in outcomes evident from the unacceptably low number of persons who are diagnosed in time, treated in time, and who achieve appropriate therapeutic goals. Taking ‘the rule of halves’ as a guide, perhaps just one out of eight individuals with diabetes achieves HbA1c targets3.
Unhealthy behaviour, attitude or practices are the basic barriers to good glucose control. Relatively less emphasis is laid on pharmacological management and its relationship to behaviour or attitudes. This is surprising, as it is well-documented that lifestyle modification alone does not suffice, and that the majority of people with diabetes will need drug therapy including insulin at some time4. Clinical inertia related to prescription and acceptance of appropriate modern pharmacotherapy is well documented in diabetes literature. This is especially true for injectable therapy, specifically insulin5. Delayed initiation or intensification of insulin is also associated with higher long-term medical costs, and a greater economic burden on society6.
The concept of social pharmacology is also well described7, and has been suggested to be a patient-centered, or person-centered framework as opposed to a drug-oriented one8. This science is extremely important for a chronic condition such as diabetes, which impacts virtually every aspect of social life, including food, exercise, and inter-personal relationships. It is not surprising that diabetes has been termed a family disease or a community illness9, and that the family is taken as an integral part in the fight against diabetes10. It can be assumed that the family or community should be targeted to ensure better healthcare seeking and accepting behaviour, including use of glucose-lowering drugs, like insulin. This can be achieved by systematic and scientific social marketing.
The term social marketing was coined by Kotler and Zaltman11, keeping ‘social good’ as a primary aim and not focusing on commercial or financial gains.
India has been a trailblazer in the use of marketing techniques in public health. The first documented use of modern marketing strategies to achieve social good is from Calcutta, where Chandy et al. proposed and implemented a national family planning programme, which encouraged the use of low cost good quality barrier contraceptives, supporting it with an integrated consumer and retailer marketing campaign12. Other countries, including both developed and developing nations, followed suit, with active government backing in many cases.
Social marketing of insulin
As the final goal of social marketing is societal good (good glycemic control, and complication-free diabetes, in this case), timely use of insulin (which helps achieve this goal) can be considered an apt social marketing intervention.
Social marketing should be differentiated from routine marketing strategies meant to promote specific services and organisational aims13. For example, a sustained campaign to encourage timely insulin usage, without mentioning brand names or products, may be considered social marketing, while a drive to increase sales of a particular drug cannot be discussed under this umbrella.
Critics may disparage this argument, pointing to the ‘pharmaceutical’ nature of insulin, and the profit orientation of insulin manufacturers. It must be noted, however, that ‘classic’ social marketing campaigns have promoted pharma interventions (oral contraceptives, vaccines, oral rehydration solution, nicotine substitutes) and for profit products (condoms, helmets) without facing such criticism. Insulin use, therefore, can be promoted as a part of social marketing.
SMART – An effective tool for the social marketing of insulin
A well designed tool, the Social Marketing Assessment and Response Tool (SMART), has been developed to help systematic study of various social marketing interventions in this regard14. The SMART lists various steps involved in creating an effective social marketing intervention. It is ironic that while all required information and knowledge is available regarding timely insulin use, this has not been collected and utilised for purposes of social marketing so far. The first step in crafting a social marketing strategy is preliminary planning14. In the case of insulin therapy, our problem of interest is lack of timely initiation and intensification.
This brings us to the next steps in SMART, which together are termed as formative research14. Formative research includes identification of the wants and needs of the target audience, and factors that influence its behaviour. If diabetes care is teamwork, so is insulin use. The healthcare professional, the person living with diabetes, the family, and the community at large, all play an important role in insulin use15. This implies that social marketing campaigns must be aimed at all these stakeholders, viz, healthcare professionals, persons living with diabetes, their families and their communities.
Channel analysis, the next step, involves identification of preferred communication methods used by the intended audience, with an assessment of their relative importance and influence14. Channels may include mass media, such as television, radio, print publications; online media, including internet, blogs and twitter accounts; and focused channels, like professional journals or patient support groups16. Market analysis is an important step in planning a social marketing campaign14. This encompasses identification of partners, allies, competitors and ‘foes’ working in the same arena. Examples of partners and allies include organisations working for general health promotion, healthy lifestyle, healthy environment, early diagnosis of diabetes and its complications, and optimal glucose monitoring. Competition may refer to schools of thought which promote the use of alternatives to insulin, such as quadruple oral combination therapy, even in persons with poorly controlled HbA1c. The term ‘foe’ may be used to describe players who defend and propagate unvalidated, unscientific approaches to the management of diabetes, viz, unproven alternative or complementary systems of medical care, which lack robust evidence-based support.
4Ps of marketing
Once friends and foes are recognised, market analysis emphasises preparation of the right ‘marketing mix’ of 4Ps (product, price, place and promotion). It must be noted here that the price paid by an insulin-user (i.e. consumer) is often intangible in nature, and must be given due weightage. The 4P marketing mix should be able to weigh the price against the perceived value of the product, and create a beneficial cost: benefit ratio for insulin use. While our product is straight forward (timely use of insulin), the intangible or non-financial price paid for insulin adoption must be explored in detail. This may include time spent in attending continuing medical education (CME), and time spent in counselling patients, for the healthcare professional17. For the patient, insulin use may imply loss of flexibility and freedom in lifestyle, and acceptance of intrusion into one’s preferred lifestyle18. The family may feel it has to pay a price by restricting social activities such as travel and leisure, or by changing dietary patterns19. The community or society, too, shares a part of the price as it meets its obligation of providing a diabetes-friendly environment20.
A complete formative analysis or research is followed by development which is a continuous activity, with ongoing evaluation, and frequent midstream correction or modification. Once the final product (strategies, tactics, methods) is ready, it is ready for implementation or activation. Implementation should be accompanied by monitoring, using various validated or pretested means of assessment. The 4Ps, as applied to insulin initiation and intensification, are listed below:
Product: It refers to the idea/ behaviour/ service/ tangible item i.e., insulin. Insulin use entails timely insulin initiation/ intensification and it requires prescription, acceptance, adherence and persistence.
Price: In this case it indicates the psychological tangible price that has to be paid for product adoption. For the patient, insulin use may imply several fears – fear of injection, fear of hypoglycemia and weight gain, fear of inability to handle insulin administration or being able to monitor adverse events, fear of the reaction of the family, fear of social ostracisation. To counter this, marketing of the benefits
of insulin needs to be done and patients or their family members need to be reassured that their fears are largely untrue.
Place: Place is where consumers are exposed to communication/ receive product. For insulin use, all persons with diabetes, their family members, all healthcare settings and all healthcare portals/ channels constitute place. While the place is the diabetes care setting, pre-marketing and post-marketing is universal.
Promotion: Means of communication that can deliver the message to target audience include mass media, person to person and community – based portals. Promotion requires multiple channels, focusing on multiple targets.
Boost for social marketing of diabetes
The social marketing of diabetes care received a much-needed and well deserved fillip, when the World Health Organization (WHO) and International Diabetes Federation declared November 14 as World Diabetes Day, to be celebrated globally. This year, the WHO has helped the diabetes social marketing movement by choosing diabetes as its focus for World Health Day (7 April), with the theme ‘Beat Diabetes’.
For the past few years, Injection Technique Day has been celebrated on January 11, to commemorate the first insulin dose administered by Dr Ed Jeffery to Leonard Thompson in Toronto. The week from January 11 to 17 is observed as Injection Technique Week.
Various celebrities, such as Wasim Akram and Sachin Tendulkar have lent their voice to social marketing campaigns in the recent past. Most of these campaigns, however, are run by private firms and organisations. This is in sharp contrast to social marketing policies for other public health issues, such as immunisation, sanitation and maternal health, where the government takes a proactive role in spreading awareness and encouraging healthy behaviours.
Public-private partnerships already exist in India, with regards to diabetes care, especially insulin usage. Examples include the Changing Diabetes Barometer (CDB), Changing Diabetes in Children (CDiC) project, which are running successfully in many states of the country. The Public Health Foundation of India (PHFI) has tied up with state governments (such as Madhya Pradesh) to train public sector doctors in diabetes care. Their comprehensive programmes include detailed discussion on insulin therapy, and facilitate timely usage of this treatment modality.
Such public-private partnerships should be strengthened, and a concerted, nationwide social marketing policy created to enhance insulin usage. Awareness about the science and art of social marketing should be coupled with knowledge of the art and science of insulin use. Working as a team, social marketers and diabetes care professionals should be able to achieve timelier acceptance and usage of insulin, thus allowing more persons with diabetes to benefit from advances in therapy.
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