Department of Anthropology, Durham University, Dawson Building, South Road, Durham DH1 3LE, UK.
Soc Sci Med. 2013 Apr;83:133-41. doi: 10.1016/j.socscimed.2013.01.036. Epub 2013 Feb 11.
Health interventions increasingly rely on formative qualitative research and social marketing techniques to effect behavioural change. Few studies, however, incorporate qualitative research into the process of program evaluation to understand both impact and reach: namely, to what extent behaviour change interventions work, for whom, in what contexts, and why. We reflect on the success of a community-based hygiene intervention conducted in the slums of Kathmandu, Nepal, evaluating both maternal behaviour and infant health. We recruited all available mother-infant pairs (n = 88), and allocated them to control and intervention groups. Formative qualitative research on hand-washing practices included structured observations of 75 mothers, 3 focus groups, and 26 in-depth interviews. Our intervention was led by Community Motivators, intensively promoting hand-washing-with-soap at key junctures of food and faeces contamination. The 6-month evaluation period included hand-washing and morbidity rates, participant observation, systematic records of fortnightly community meetings, and follow-up interviews with 12 mothers. While quantitative measures demonstrated improvement in hand-washing rates and a 40% reduction in child diarrhoea, the qualitative data highlighted important equity issues in reaching the ultra-poor. We argue that a social marketing approach is inherently limited: focussing on individual agency, rather than structural conditions constraining behaviour, can unwittingly exacerbate health inequity. This contributes to a prevention paradox whereby those with the greatest need of a health intervention are least likely to benefit, finding hand-washing in the slums to be irrelevant or futile. Thus social marketing is best deployed within a range of interventions that address the structural as well as the behavioural and cognitive drivers of behaviour change. We conclude that critiques of social marketing have not paid sufficient attention to issues of health equity, and demonstrate how this can be addressed with qualitative data, embedded in both the formative and evaluative phases of a health intervention.
健康干预措施越来越依赖形成性定性研究和社会营销技术来实现行为改变。然而，很少有研究将定性研究纳入方案评估过程中，以了解影响和覆盖范围：即行为改变干预措施的效果如何、针对谁、在什么情况下以及为什么。我们反思了在尼泊尔加德满都贫民窟进行的一项基于社区的卫生干预措施的成功，评估了母婴行为和婴儿健康。我们招募了所有可用的母婴对（n=88），并将他们分配到对照组和干预组。关于洗手习惯的形成性定性研究包括对 75 位母亲进行了结构性观察、3 个焦点小组和 26 次深入访谈。我们的干预措施由社区激励者主导，在食物和粪便污染的关键节点大力推广用肥皂洗手。6 个月的评估期包括洗手和发病率、参与者观察、每两周社区会议的系统记录以及对 12 位母亲的后续访谈。虽然定量措施显示洗手率有所提高，儿童腹泻率降低了 40%，但定性数据突出了在接触极端贫困人口方面的重要公平问题。我们认为，社会营销方法本质上是有限的：关注个人代理，而不是限制行为的结构性条件，可能会无意中加剧健康不平等。这导致了预防悖论，即那些最需要健康干预的人最不可能受益，他们认为在贫民窟洗手是无关紧要或徒劳的。因此，社会营销最好在一系列干预措施中部署，这些措施既可以解决行为改变的结构性驱动因素，也可以解决行为和认知驱动因素。我们得出的结论是，对社会营销的批评没有充分关注健康公平问题，并展示了如何通过定性数据来解决这些问题，这些数据嵌入了健康干预的形成和评估阶段。
