Social Marketing: A Pathway to Reduce the Economic Burden of Noncommunicable Diseases in Pakistan

In developing countries like Pakistan, social issues have kept the developmental activities back and persistently aggravated the hardships of common people. This, in turn, undermines to take new initiative and is one of the major impediments to developing an enterprising workforce. This article discusses the importance of marketing to address noncommunicable diseases (NCDs) from a social marketing perspective, NCDs approximately cause four million deaths annually. Pakistan is a signatory of Sustainable Development Goals (SDGs) and promoting good health is the heart of achieving and delivering on 2030 sustainable development agenda. Efforts to reduce obesity so far are not successful despite several measures taken globally. This paper seeks the efficacy of social marketing using group-centered approaches to reduce the economic burden of noncommunicable diseases. The efficacy of group-centered approaches in the context of social marketing was explored to address social and health issues confronted by various countries.


Introduction
In developing countries like Pakistan, social issues have kept back development activities and persistently aggravating the hardships of common people. This, in turn, undermines to take new initiative and it is one of the major impediments to developing an enterprising workforce. This vicious circle has deprived people to have decent living standards and the right to exercise basic constitutional rights. These issues have been highlighted by many social science scholars in the field of development. It is, however, important to note that the work of Achrol and Kotler (2016) has very convincingly argued that how the field of marketing and its subfield social marketing provides quite comprehensive tools and techniques to position these issues as well as modalities to overcome them. All these issues and problems in health, food, drinking water, energy, clean air, education, and other essentials of the social safety net are quite pervasive that most of the common people encounter. It is particularly important to examine some of the issues from the perspective of the public in a relation to public health and hygiene, clean drinking water, education, justice, environmental degradation, and climate change, supporting communities at the grassroots level who are languishing in poverty and hunger, etc. This research sums up why people are hardly being induced towards health-seeking behaviour using social marketing. In this context, a noncommunicable disease in health is one of the predicaments that undermine the quality of life of the people across the communities and quite detrimental in its outcome for the victim and his family. In this backdrop, this research is carried out to see the efficacy of social marketing using interactive and participatory paradigm, a progeny of group dynamics to bring about desired behaviour change.
The sustainable development agenda was approved by the United Nations General Assembly in September 2015 as the successor to the Millennium Development Goals (MDGs). The 17 goals of SDGs have 169 targets, notable ones are ending poverty and hunger, improving health and education, making cities more sustainable, combating climate change, and protecting oceans and forests. The health goal 3 states that health and wellbeing be given centrality in SDGs, keeping in view the fact that it is a matter of great concern for all. Goal 3 of SDGs states "Ensure healthy lives and promote well-being for all at all ages" and it is sub-goal 4 says "By 2030, reduce by one-third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and wellbeing". One of the areas that are quite evident is non-communicable diseases (NCDs). It has been reported by Global Biomedical Sciences (GBS, 2015) that NCDs approximately cause four million deaths annually, which contributes approximately 70% of global deaths. Unfortunately, developing countries contribute 70% of the major chunk. The unhealthy lifestyle like physical inactivity, tobacco use, and use of alcohol are the major sources of NCDs. (GBS 2015). NCDs include four major diseases i.e. cancer, diabetes, cardiovascular disease, and chronic respiratory disease. The NCDs are also referred to as "lifestyle" diseases. NCDs distress global socioeconomic opportunities and indirect costs to society. It has been reported that by 2030 its burden to the global economies would be $47 trillion (Bloom et.al., 2012). It is also pertinent to mention that for NCDs, Pakistan doesn't have a national policy or action plan to address NCDs due to physical inactivity / or physical activity promotion policy. This raises the question of public policy and marketing an emerging area of inquiry. Moreover, a recent report on world happiness released by United Nations highlighted that prevalence of obesity is increasing day by day in the world including the USA . Pakistan among 80 happiest countries in the world happiness report released by UN in (Iqbal, 2018) while because obesity Pakistan stands at number 9 (The express Tribune 2014).

NCDs as a Risk Associated with lack of Exercise
Pakistan is a signatory of Sustainable Development Goals (SDGs) and promoting good health is the heart of achieving and delivering on 2030 sustainable development agenda. Efforts to reduce obesity so far are not successful overall despite several measures taken globally. The process of how consumers act because of social marketing campaigns is of utmost importance (Krishen and Buib, 2014). Pakistan Medical Research Council has published a list of ten most common distortions in males and females based on the data collected from six radiotherapy departments of the country. The report stated that intestinal cancer ranked the sixth most common cancer in males with an incidence rate of 5.7%, but did not find a place in the list of ten most common tumors in females. In 1995-1999, in a population-based study by Karachi Cancer Registry, colorectal cancer ranked sixth but its incidence rate decreased to 4.1%. In females, it ranked ninth but its incidence rate was 5% (Javed, 2006). Although several studies have been done to record the incidence of colorectal cancer the changing environment, demographics, and fatal nature of the disease necessitates an ongoing process of continuously recording this data. A recent study conducted by Qaisar (2015) found that 92% of public sector employees in Pakistan reported that they remain unable to regularly engage in physical activities. He suggested a need for such workplace wellness measures to increase awareness, enhance motivation, build skills, and create opportunities for employees so that they could engaging in healthy physical activities as the easiest choice for them.
There is evidence highlighting that due to physical inactivity people are suffering from colon cancers (Lee, 2003). Colon cancer is a preventable disease but it's on the rise worldwide especially in the USA it is badly affecting the lives of many people and ranked at number three with an estimated case diagnosis every year around 112000 (Wiseman, 2008). Several measures can prevent this disease (Martinez, 2005). The evidence shows that regular physical activity can prevent this disease (Samad, Taylor, Marshall, & Chapman 2005). The people who are physically active as compared to inactive people have 40% fewer chances to develop risk for colon cancer (Lee, 2003). It is also evident that regular physical activity helps in combating this cancer in a dose-response manner (Thune, & Furberg, 2001). Physical inactivity leads to obesity, compared to those who are with normal weight or healthy weight, obese people have more chances to develop an increased risk of dying due to cardiovascular disease, diabetes, strokes, osteoarthritis, sleep apnea, and certain cancers. Obesity also accounts for depression, anxiety, and many chronic health diseases (Harvard Public Health, 2017). As per Lancet 2016 people around the world are getting heavier and the USA is taking the lead. Over the last 40 years, the world population's average weight has become about 3.3 pounds heavier each decade. If the post-2000 trends continue the same way, then there will be a big question mark on meeting the global obesity reduction targets. Among developed and high-income countries America has the highest obesity. In the USA alone due to physical inactivity, more than 14% of people are suffering from colon cancer (Friedenreich, 2001;Slattery, Edwards, Friedman, & Potter, 1997). Several studies found that due to colon cancer social marketing campaigns people go for getting more information and modifying their behavior.

Social Marketing showed Inconclusive results towards Sustained behaviour Changes
There was a big question mark on social marketing towards sustained behavior changes to achieve many development and health-related goals. The major reason for the long-term impact of social marketing campaigns was the usage of traditional approaches in social marketing and that they focused on individual-centered approaches and group-centered approaches were not taken into consideration (Khan, 2014). It is important to mention here that social issues and problems are not individual problems but those are community or society level problems. As social marketing is a sub-domain of marketing, so all the approaches which were employed in the social marketing field were individual focused. Social problems are not individual problems and they need group centered approached to address social and health issues. Some leading scholars pointed out that various theories and techniques used in social marketing have limitations (Achrol & Kotler, 2016). However, the past literature in social marketing has not employed a participatory paradigm to create long term impacts of the campaigns. Various social issues faced by the developing countries are hindering their progress to achieve their economic, health and wellbeing goals of the developing countries (Critchlow, & Donald, 1998). Therefore, there is a need to bring interactive paradigm in social marketing campaigns, focusing group as a unit of analysis to reduce the economic burden of noncommunicable diseases in the developing countries. As group centered approaches have shown better results towards various social change programs.

Inculcating Participatory Paradigm in Social Marketing for Sustained behavior Changes
Group centered approaches assume that free and fair interaction discussion generate valuable discussion if carried out without any social prejudice's mechanism is quite important that undertake wellbeing of the community and persuade them to perform prosocial behavior and healthy activities as a function of interaction. Moreover, the interaction, in turn, creates conditions for equal opportunity among the group members to participate and contribute to advance the good of the community (Khan, 2005). Because of effective participation members not only identify hard pressing issues that undermine their wellbeing and overall welfare of the community members. They also seek opportunities to resolve through productive actions and activities. The interactive process offloads their sense of diffidence, apprehensions, and uncertainty of the outcomes that they were carrying-out before interaction. In brief, group-centred approaches examine the explanatory power of social marketing both conceptually and its practical outcomes. As rightly said, that: "Objects of study in group dynamics are collectivities such as a family, a workplace, an organization, a community, and so on. A concept of collectivity includes not only people but their physical and institutional environments. A collectivity changes like a living thing. Change of a collectivity, the dynamic nature of a collectivity, is a research target of group dynamics" (Sugiman, 2015, p.8.) Group centered approaches provide a comprehensive theoretical base that likely to add incremental value towards advancing the core purpose of social marketing. It also mitigates the potential biases of conventional approaches/ theories used in marketing that disregard the majority (Hill & Martin, 2014) of public concerns by promoting humanistic and democratic norms to advance consumer/ public welfare not only help inaptly appreciate the context which is prerequisite to take appropriate modalities to counter social undesired social habits that may tend to indulge the community members to trap in unhealthy lifestyles. Hill and Martin quite forcefully argued that there is need to broaden the perspective of the marketing field, the authors argued, most theories and practices strip away people's heterogeneity in favor of simplistic ways of measuring success (Hill & Martin, 2014). Surprisingly a recent article by Wiener et.al (2018) trying to promote prosocial behavior preferring to use individual-centered approaches. Whereas Hill and Martin (2014) making effort to advance the frontier of researches of marketing with kind of scholarship that provides better answers to reduce the economic burden of noncommunicable diseases as conventional approaches could hardly be successful keeping in view the changing reality of the modern world of communication that reinforce respect and responsibility. In brief, these kinds of intellectual resistance could only be offloaded if marketing particularly social marketing harness a comprehensive theoretical base that helps provides a prudent process to explain the social phenomenon and address desired behavior change. For this, the process of group-centered approaches offers a quite effective social mechanism to discharge social marketing initiatives to counter such negative social habits by engaging people through continuous discourse and discussions that make them realize how these activities undermine their quality of life in the long run. And they may end up with physical and psychological disorders. Besides the become victim of NCDs. As a result of if they keep up those bad social habits. This realization process provides them the opportunity to initiate some healthy activities. In the gradual process continuation of these activities reinforce the social habits as a counter. In other words, poor social habits cannot be countered through conventional promotional techniques. They can only be broken by offering a counter habit. In this case, physical activity is a counter social habit to offload undesired social habits. In other words, group-centered approaches are a comprehensive theoretical framework that not only help in identifying the underline forces that impediment to improving quality of life of the community members but at the same time they seek possible solutions amicably resolve modalities to implement in befitting manners (Kotler, 2015(Kotler, , 2016.

Way forward to address NCDs using Social Marketing
In the present age of information, knowledge and access to communication devices are quite pervasive. It is, however, quite unfortunate that people are dying with hunger, malnutrition, and non-communicable diseases. We would have prevented such tragedies if we had been well-positioned in our prevention and behavior change program using requisite social mechanisms rather than lamenting on planned behavior and other conventional models in social change program initiatives. Social marketing is a valuable tool to facilitate social and development reforms, both at macro and micro level interventions using interactive paradigm based on group-centred approaches. This way it tends to broaden the social context using an interactive and participatory paradigm that brings about desired social and behavior change among the target segment, audience, community, or society. To understand the psychosocial reality of the target community and their unhealthy life patterns need to be deciphered. The social mechanism that interactive paradigm is likely to build as a function of group interaction among the community members provides an opportunity to identify their problems and that is an impediment to seek health-seeking behavior and activities to healthy lifestyle culture, like social norms (a weighted benefit that an activity generates) in addressing issues related to obesity and diet. It is a matter of great concern to all key stakeholders aiming to promote a healthy lifestyle, to counter social stress. In this regard, social marketing professionals, policymakers, and social science researchers need social marketing that employs group-centred approaches as a strategic tool. It is alarming that the incidence of obesity is increasing day by day in the entire world; according to the study published in Lancet 2014 ranked Pakistan at 9 th out of 188 countries because of obesity. This study, in a real sense, also highlighted that none of the countries is so far able to address the issue of obesity since 1980. Among ten most obese countries in the world, USA stands at 1 st , China trailed at 2 nd while India falls at number 3, followed by Russia, Brazil, Mexico, Egypt, Germany, Pakistan, and Indonesia (Lancet, 2014). The report published by Lancet (2014) also pointed out that a quarter of children are overweight while one-third of adults fall in the category of obesity. The report reflects that although obesity is persistently growing in the entire world however, more than 60 per cent of people with obesity are now living in developing countries.
The conventional approaches have delivered some services but a new approach based on participatory paradigm using group centred as bases to develop effective tools and techniques are quite powerful that not only aptly identifying the core social issues through an interactive process of community where the problem lies but also participant identify modalities to address the problem sustainably besides resource-constrained economies societies like Pakistan. In this situation, it has become quite evident that marketing particularly social marketing scholars and professionals address health issues that are caused due to NCDs. Achrol and Kotler (2016) and Khan (2007Khan ( , 2008Khan ( , and 2014 highlighted the importance of social marketing group centred approaches rather using conventional methods that have been used in sociology, psychology, social economics and anthropology to address social and development issues however group dynamics as a strategic tool to augment behavior change has shown better results.

Conclusion
Social marketing using group-centered approaches can be a very effective tool to reduce the economic burden of lifestyle diseases like NCDs. The evidence is quite clear that social marketing programs in Pakistan have hardly brought sustained behavior changes; therefore, an interactive paradigm in social marketing can be a very effective tool to address issues related to health and to overcome NCDs. The failure of family planning social marketing campaigns and polio eradication campaigns in Pakistan ask scholars to bring a fresh angle to social marketing programs to achieve development goals.