The Role of the Registered Nurse in the Marketing of Primary Healthcare Services, as Part of Health Promotion

Curationis 29(1): 10-24 Primary health care, marketing, Existing literature on the marketing of primary healthcare services was reviewed to health promotion, role of nurses determine the role of registered nurses in this regard. The systematic review included ■ " — f i v e searches and ensured wide coverage of the results of available primary research studies on the topic. The results were summarised and the role of registered nurses in the marketing of primary healthcare services was identified. Primary research sources on the topic included textbooks on marketing by experts in the field and relevant journal articles by authorities on healthcare marketing. The data were analysed and four main categories identified. To ensure the trustworthiness of the research, Lincoln and Guba's (1981:215-216) criteria, as explained by Krefting (1991:217), were applied. Because the population consisted of only literature, ethical considerations concerning human subjects were irrelevant. Results indicated that the basic commercial marketing principles (the so-called 4Ps-product, price, place, and promotion) could be adapted for the health sector. The conclusion was that registered nurses could contribute to the marketing of primary healthcare services by communicating with the community (promotion) and by ensuring effective service (product) delivery at the right price and place. Registered nurses could influence the community's perceptions of health care and facilitate behaviour changes, thereby promote health. The implementation of the findings and recommendations of this research could create a new awareness among registered nurses of their role in the marketing of primary healthcare services in South Africa and improve their skills in this regard. Opsomming Bestaande literatuur oor die bemarking van primêre gesondheidsorgdienste is krities beoordeel om die rol van die geregistreerde verpleegkundige in hierdie verband te bepaal. Die sistematiese kritiese beskouing het vyf literatuursoektogte behels en wye dekking van die resultate van beskikbare primêre navorsingstudies oor die onderwerp verseker. Die resultate is opgesom en die rol van geregistreerde verpleegkundiges in die bemarking van primêre gesondheidsorgdienste bepaal. Primêre navorsingsbronne oor die onderwerp het handboeke oor bemarking deur kundiges in die veld en aktuele wetenskaplike tydskrifartikels deur gesaghebbendes oor gesondheidsorgbemarking ingesluit. Die data is geanaliseer en vier hoofkategorieë geïdentifiseer. Om die betroubaarheid van die navorsing te verseker, is Lincoln en Guba (1981:215-16) se kriteria, soos deur Krefting (1991:217) bespreek, toegepas. Aangesien die populasie slegs uit literatuur bestaan het, was etiese oorwegings, wat ten opsigte van menslike subjekte geld, irrelev an t. Die re su ltate het aangedui dat die …


Introduction
A literature review was conducted to determine the role of registered nurses in the m arketing of primary healthcare services, as part of health promotion.The research design and methodology, the in te rp re ta tio n o f the data, and the re co m m en d atio n s m ade, w ill be discussed.

Problem statement
Following the statement by the African National Congress that every individual has the right to achieve optimal health (ANC 1994), the mission statement issued by the South African D epartm ent of H ealth becom es clear: "To provide leadership and guidance to the NHS (National Health System) in its efforts to promote and monitor the health of all people in South Africa; and to provide caring and effective services through the primary healthcare approach" (Dennill, King & Swanepoel 1999:170).
However, if primary healthcare servjces are unavailable or inaccessible to the community, inter alia due to lack of knowledge, optimal health cannot be achieved.M arketing o f healthcare services is a relatively new concept in the non-profit healthcare industry.As the emphasis is not on profit making, but on service delivery, marketing of primary healthcare services is seen as an uphill task.The extent of the involvement of the community health nurse/registered nurse in the marketing of services should not be underestimated.If communities w ere n o t in fo rm ed about prim ary healthcare services, in other words, if these se rv ic e s w ere not m arketed, accessibility, equity and availability could not be ensured.

Aim of the research
By reviewing literature on the topic, the researcher aimed to determine the role of registered nurses in the marketing of primary healthcare services.

Research question
To achieve this aim , the follow ing research question was formulated: What role does registered nurses play in the m a rke tin g o f p rim a ry hea lth ca re services as part o f health promotion?
The research objectives were formulated as sub-questions: • What is the registered nurse's role in the marketing of primary healthcare services?• How can the registered nurse use marketing to promote health?• What should be in place to enable the registered nurse to deliver health services?• How can the registered nurse reach the external environment?
Relevance of the research Uncertainty exists about the role of the registered nurse in the m arketing of primary healthcare services.Through marketing, healthcare services can be made more available and accessible to the community, and health be promoted.
The system atic review of available evidence on the role o f nurses in the marketing of primary healthcare services p ro v id ed answ ers to the re searc h question.The synthesised data can assist decision-making on the delivery of health care and the planning of new primary research.

Research design and methodology
Qualitative research was conducted by applying systematic review methods.A good review should focus on welldefined questions and the methodology be g eared tow ard o btain in g valid answers.In this research, the reviewer was determined to search for all literature relevant to the research question.Criteria for selecting or rejecting studies have to be determined.All literature included in the research should directly address the research question.
For this study, thirty-four journal articles w ere gath ered from the M ed lin e database.Six textbooks on marketing, written by experts in the field, were selected and used.The relatively small sample of relevant literature enabled the researcher to focus on the research topic.

Data analysis
According to De Vos, Strydom, Fouche, Poggenpoel, Schurink and Schurink (1998:337), there is no right or wrong approach to performing data analysis.However, the researcher should be able to logically account for all stages of the data analysis.The conclusion should be based on the generated data.
An adapted version of Tesch's (1990:154-6) model for qualitative data analysis, as described by Creswell (1994:154-6), was used for this study.The researcher tried to make sense of the whole by reading

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through the journal articles and textbooks and by writing down ideas as they came to mind.These steps were taken to determine the underlying meaning of the data.
Four main categories emerged from the data obtained, namely: 1.
The purpose of marketing primary healthcare services; 2.
The plan of action; 3.
Making these services available; and 4.
The realisation of external/ community ownership.
The categories were colour coded.(1996:3-12), different files were createdthe master file contained the original raw data and the analytical files the data on the categories.The study report was structured according to the sets of data organised into the analytical files.

Trustworthiness
Reviews should be assessed and critically appraised for quality.Quality can be d efin ed as co n fid ence that bias is minimised by the design, conduct and analysis of the review (CRD Publications Office 2001).Quality assessment is important because the effectiveness of in terv e n tio n s may be m asked or exaggerated by reviews that are not rigorously conducted.
The process whereby study relevance and quality are assessed, should be unbiased, reproducible and transparent.If this process is not well documented, confidence in the results of a review is weakened.The review should clearly display the results of all studies included, highlight any similarities or differences and explore the reasons for variations.
In light of these results, and considering the p o p u latio n , in terv en tio n s and outcom es covered by the review, it should be possible to make a judgment about the applicability and value of the review 's findings (CRD Publications Office 2001).
Lincoln and Guba's (1981:215-16) criteria for assessin g tru stw o rth in ess, as discussed by Krefting (1991:217), were used to ensure a quality review.These criteria are as follows: • Truth value/Credibility: Confidence in the truth of the data was established by making use of multiple references, a technique known as data source triangulation.

• Applicability/Transferability:
Using articles published in acclaimed journals and researching the role of the registered nurse in the context of national health systems improved the possibility of fitting findings/results into contexts outside this study situation.

Confirmability:
In qualitative studies, confirmability does not focus on the characteristics of the re searc h er (is s/he o b jectiv e and unbiased?),but rather focuses on the characteristics of the data (is the data confirmable? ).An inquiry audit can be used to establish both dependability and confirmability of data (Polit & Hungler 1997:307).
An up-to-date, published, systematic review of good quality can be used to guide healthcare decisions.However, it is p ossible to update or ex ten d a published review of reasonable quality to generate the information required (CRD Publications Office 2001).

Ethical considerations
The p o p u latio n for this research consisted of journal articles, reviews, and textbook data.Human beings were not used as subjects; therefore, ethical c o n sid eratio n s, such as selfdeterm ination, privacy, anonym ity, confidentiality, protection from harm, and informed consent, were irrelevant.

Limitations of the study
Only one database, Medline, was used for the retrieval of information.As more databases would have produced more data, this could be seen as a limitation of the study.However, this was a study of limited scope, and the limitation ought not to have had a significant effect on results.A further limitation was the number of South African sources found.M ost data w ere retriev ed from internationally acclaimed journals.

Literature search strategy
The aim of the literature search was to generate a comprehensive list of primary studies on the research topic that could be used for answ ering the research question.The strategy for identifying relevant studies has to be thorough and unbiased, because the validity of findings is d irec tly re la te d to the co m p reh en siv en ess o f the search.Moreover, the level of precision in the effect estimate that can be generated by a systematic review depends upon the volume of information included in the review.It is important to be aware of the range of potential biases and to use a v ariety o f search m eth o d s (both computerised and manual) to ensure a comprehensive search (CRD Publications Office 2001).For the purposes of this study, five searches were conducted.

Search 1
Inform ation on m arketing that was discussed as part of a master's course in community health nursing, as well as journal articles on marketing of health services found on the Internet in June 2002, was set aside for future reference.The eighteen articles found on the M edline database are sum m arised in Table 1.
Relevant articles from accredited journals were screened for arguments on:   After reading the abstracts to determine usability, eleven articles were selected.A summary of the selected articles is included as Table 4.

Search 4
Applying the search term 'marketing of health', data about relevant textbooks were retrieved from UP Explorer, the browser for the Intranet of the University of Pretoria.Textbooks used for previous studies also proved to be useful, as they contained information on the topic of this research.The textbooks used and the authors' fields of interest are listed in Table 5.

Search 5
An a d d itio n a l, m anual search was conducted to find sources to assist in the formulation of the research design and methodology, as well as the analysis of data.These sources are summarised in Table 6.

Conclusions and recommendations
T he v iew s o f a u th o rs/ex p e rts on commercial and social marketing were analysed and categorised.Conclusions were drawn about:

The role of the registered nurse in the marketing of healthcare services
The South African national healthcare plan is based on the belief that every individual has the right to achieve optimal health.If primary healthcare services were available, affordable, effective and accessible, the community would be aware of these services.Thus, as part of health promotion, the registered nurse has to assist in the marketing of primary healthcare services.
To ensure equal access to quality health care, the South African government has to create, m onitor and, if necessary, change the fram ew ork or system of healthcare delivery (Dennill et al. 1999:42).
Changes to healthcare delivery planned in 1994 were aimed at the decentralisation of services, with the emphasis on primary healthcare delivery and community care.
The proposed system allow ed for a continuum of health care, with a referral system that would permit easy, logical

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movement between primary, secondary and tertiary services.If the structure for delivering these services were in place, the registered nurse could assist in promoting primary healthcare services.

Conclusions
W hen the key concepts of this study were clarified, it becam e clear that d iffe ren t authors had a m utual understanding of the concept 'marketing' (Refer to  The registered nurse has to identify the target group's specific needs.This will ensure that the customer purchases the health product/service.A relationship of trust betw een registered nurses and customers will facilitate the process of needs assessment. A ccording to W eiss (2002 :1 2 ,1 3 ), advertising drives marketing.This, how ever, is a m yth that persists.Advertising helps to increase visibility, aw aren ess, u n d erstanding and positioning in health care.Relationships though, drive results.A relationship of trust between the registered nurse and the customer will help create a supportive clim ate in which the custom er will experience a sense of security (Dennill et al. 1999:146).In a climate of trust and support, the registered nurse will be considered the most reliable source of h ea lth -related inform ation.Such a relationship will enable the nurse to fa cilitate adju stm en ts, such as the development of behaviour that promotes health.

•
Registered nurses should take responsibility for co-coordinating clinical and marketing departments by sharing their knowledge on healthcare services and their understan ding of patients' needs.questions to ask and knowing how to listen to the answer."

Conclusions
Conclusions were drawn about registered nurses' involvement in social marketing and health promotion.

• Social marketing
The research also focused on the role that registered nurses could play in a plan of action to facilitate adjustments and promote healthy lifestyles.Hillestad and Berkowitz (1991:18), as well as Perreault and M cCarthy (2002:14), stated that m arketing fa cilitates the voluntary exchange of item s.In a non-profit primary healthcare clinic, services are ren d ered free o f charge, but the ex p e ctatio n is that custom ers w ill voluntarily change their behaviour to im prove their health.R efer to the definitions of social marketing set out in Table 9. Andreason (1995:8) 2002).By keeping the customer's social context and cultural background in mind, the registered nurse will be able to offer health information that is relevant and useful.
According to Perreault and McCarthy (2002:42), as well as Pine and Gilmore (2001:13), customers will reject a service/ p ro d u ct if they see one featu re as substandard.Because a positive attitude will promote compliance, participation and the health of the customer, registered n u rses should en courage such an attitu d e tow ard prim ary healthcare services and behavioural change.

* Health promotion
Americans are moving away from the idea that health is the absence of disease and the result of medical intervention.
They are accepting a broader definition, w hich in clu d es both personal responsibility and quality of life, with self-care and prevention as key words.Individuals are taking a more pro-active ap p ro ach to h ealth care, seeking information and adjusting lifestyles to improve their health.This self-care trend affords nurses the opportunities to act as sources of referral.Nurses can also guide people to optimise their health by m anaging personal health risks (Dienemann 1998:187).This point of view is echoed by Van Wyk (1999:31) who • states that health prom otion enables individuals to take control of their own life/well-being.Healthy public policies and health education empower people to take responsibility for their own health.
By making informed decisions about their health and by changing behaviour, informed people know they can improve their health.Healthy public policies can create a climate that is conducive to • decision-making in this regard.Health education, also a component of health p ro m o tio n , w ill be enhanced if a supportive environment were established by means of healthy public policies (Norton 1998(Norton :1271)).

Recommendations
To change the traditional paradigm, where advice and information are given to the patient (one-way communi cation), registered nurses/ healthcare providers have to become facilitators of health.They need to work in partnership with the consumer (two-way communication).Registered nurses have to change their attitudes toward patients.Instead of labelling them as non-compliant, nurses should assume responsibility and transfer knowledge about health matters to the patient.thereby facilitating decision making.Through proper patient assessment, registered nurses have to try and solve causing factors of illness, rather than treat symptoms.Registered nurses are not in a position to change the circumstances of a patient, but they can empower the community by making them aware of their capacity to effect change.Registered nurses have to be sensitive to the social context, as well as the cultural background, of the communities they serve.Compliance may improve if they gain the respect of the community.Through marketing, available primary healthcare services can be brought to the attention of the community.Knowledge boosts confidence, and confident communities may access these services and make informed decisions.To change the perceptions of the community about healthcare services and encourage regular visits, services have to exceed expectations.Registered nurses have to ensure that services meet the community's needs.Aspects such as friendliness, respect, flexible clinic times and a proper referral  Four major tools in the marketer's toolbox, also referred to as the marketing mix, are used to influence the target market.These are: product, price, promotion and place, the so-called 4Ps.Such a marketing mix can be used to reach the important goal of delivering primary healthcare services that are available, accessible, affordable, effective, equitable, and efficient.
To achieve these objectives (availability, affordability etc.), certain strategies or requirements have to be implemented.A comparison between these strategies/ requirements, as discussed by Dennill et al. (1999:6) and Van Rensburg, Fourie and Pretorius (1992:364), is displayed in Table 10.To ensure the successful delivery of primary healthcare services, registered nurses have to strive to reach these objectives (Dennill et al. 1999:6).
The traditional 4Ps (product, price, place, prom otion), as described in the com m ercial market, are not directly applicable to the social market, although fundamental tenets hold firm.To make the marketing mix more appropriate to health services, the 4Ps were converted to service (product), cost (price), delivery (place) and com m unication m ix (prom otion) by B ax ter-D errin g to n (1995:22).Similarities that exist between the commercial market and the social market made this conversion possible.The traditional 4Ps, as w ell as the adapted 4 'P's and the corresponding prim ary health care o b jectiv es, are presented in Table 11.
According to Perreault and McCarthy (2002:248), the product/service refers to the market offering that would satisfy a specific need.The focus should be on the customer and the customer's needs.Services should also be congruent with the customer's values and desires.This will make the service acceptable to the customer.
Price/cost is what the customer has to give up to receive the benefit (Perreault & McCarthy 2002:484).In a non-profit health organisation, it is not money, but rather the customer's ability to pay a price that will promote health.This may include, for example, an investment of time, energy, and motivation.Brenkert (2002:18) describes this as a 'welfare exchange'.Because price/cost can be a barrier to the utilisation of prim ary healthcare services, it is important to make sure that services are affordable and customers receive value in exchange for investments.

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Place/delivery is concerned with all the decisions that are involved in getting the right product to the target audience (Perreault & McCarthy 2002:48).Services should be extended to be accessible to all people (Dennill et al. 1999:6).Services should be available and convenient, and accom m odate c lie n ts' needs.The therapeutic process will be enhanced by a warm, caring physical environment, which will also attract more customers.
Through promotion/the communication mix, information about the offer is given to the target audience, who is inspired to act (Kotler et al. 2002:264).The target audience is informed about the right product that is delivered at the right price and place.The relation between the 4'P 's and the primary healthcare objectives is summarised in Table 12.
W hile planning prim ary healthcare delivery, the mix of nurse attributes should also be considered.According to Livesey (1998:485), nursing skills and experience, as well as professional and social networks, are nurse attributes that form the foundation of a successful strategy for the implementation of health services.Calpin-Davis (1998:37) also explains that productivity im proves efficien cy and leads to successfu l healthcare delivery.Through excellence, compassion, social responsibility, and faith in themselves and others, registered nurses will be able to promote their services (Dana & Woods 2002:325).

Recommendations
• Registered nurses should partake in the analysis of customers' wants and needs to be able to offer satisfactory services.Social m arketing is the use of m arketing principles and techniques to influence a target audience to voluntarily accept, reject, m odify or abandon behaviour for the benefit of individuals, groups or society as a whole.
Social marketing is the 25-year-old discipline that applies the marketing technologies developed in the commercial sector to the solution of social problems, for which the bottom line is promoting behavioural change.
should be kept in mind (Refer to Table 13).A lthough the press, radio and television reach large audiences, they are expensive and lack selectivity.In the case of electronic media, the probability exists that the consum er can stop paying attention to the message (Hillestad & Berkowitz 1991:80).
Seldom nurses are directly involved in the m arketing o f prim ary healthcare services.However, they should realise that they have a role to play in informing the com m unity about these services.R egistered nurses should attem pt to design advertisements that would turn u naw areness into aw aren ess, and enthuse the community's interest in what is being offered (B axter-D errington 1995:23).
Personal attributes of registered nurses, such as friendliness, approachability and confidence, can almost instantaneously in flu en ce the h ea lth b eliefs and behaviours o f com m unity m em bers (Whitehead 2000:810).P ositive nurse attributes contribute toward good public relations, which will positively influence the com m unity's attitude toward the services delivered and encourage com m unity support (Dienemann 1998:200).No budget is needed when this route of promotion is followed, and by word of mouth the offering will be 'sold' by a satisfied community.

Reaching the external environment
Incorporating the marketing mix into healthcare planning will improve the av a ila b ility , affo rd ab ility , equity, accessibility and efficiency of primary healthcare services.Offering the right product at the right price, at a convenient place, will lead to a 'welfare exchange' between the m arketer and consumer.Promoting primary healthcare services may positively influence perceptions and increase the probability that the product will be 'purchased'.The first step is to inform the consum er about the availability of services.Consumers need information that can be seen, heard or held (Baxter-Derrington 1995:23).

Conclusions
Communication tools (such as the mass media, e.g.advertising, personal selling and public relations) are used to reach the external environment.These tools are vital to the successful m arketing of health promotion products.
In a non-profit organisation, the budget for advertising, if any, would be very low and for this reason, media should be selected with discretion.The advantages and disadvantages of different media Availability T here should be su fficien t and appropriate services to meet the particular health needs of each community.
The geographical, strategic and logistical distribution of preventative, curative and rehabilitative services should benefit all.

Affordability
The level of health care offered should be brought into alignment with the health spending capacity of the community and country.No person should be denied health care because of an inability to pay.
The price of health care should be in alignm ent with the health spending capacity of the community and no person should be denied health care because of an inability to pay.

Effectiveness
Services should provide the type of care intended for a specific com m unity.Services rendered must be justifiable in terms of total costs.
Not described.

Efficiency
In terms of effort, money, resources and tim e, the results attained should be appropriate to the input.
Not described.

Accessibility
Services must be within reach of all people in the country.Special attention should be given to p rev io u sly disadvantaged regions.Services should be g eographically, fin an cially and functionally accessible.
Accessibility implies the abolishment of geographical, financial, racial, political and other obstacles to healthcare access.

Equity
All people should have equal access to basic healthcare.There should be no discrepancy in care.
Not described.

Applicability and relevancy
Not described.
There should be a relation between services and facilities offered and the needs of the community.• Effectiveness, acceptability.
• Price: What the customer pays for the product.
• Cost: Estimated in terms of cost/ benefit, income/expenditure, people, time and effort.
• Place: The route the product travels from the manufacturer to the customer.
• Delivery: Where, when and how?
• Promotion: Means by which the company engages the customer's desire to buy the product.
• Communication mix: Means by which customers learn about services and benefits.

Table 2 : Searches 2 and 3: Information on authors
One such approach involves breaking down the research question into facets, such as p o p u latio n , in terv e n tio n s, outcome and study design.With respect Epstein, L.Not indicated.Department of Social Medicine, Hebrew University.Hadassah Brown School of Public Health and Community Medicine, Jerusalem.Rosen, R & Mountford, L. Both specialists.Registrars in public health.The K ing's Fund, London, UK.

Table 1 : Summary of the results of Search 1
M ark etin g : A n ursing lead e rsh ip imperative.Bvers.JF.2001.Nursing Economics.19(3):94-9.A ssociate Professor, U niversity of Central Florida, Orlando.Twenty years of health care marketing.Beckham.D. 2001.Health Forum Journal.44<4):37^IO.President of the Beckham Company.A m erican M arketing A sso ciatio n (AMA).Building on first impressions.Thomas.RK. 2002.Marketing Health Services.22(2):34-8.AMA.Welcome to experience economy.Iacobucci, D, Calder, BJ, Malthouse, E & Duhachek.A. 2002.Marketing Health Services.22(2): 16-20.Iacobucci: Professor of M arketing.University of Arizona.C alder: P ro fesso r o f M arketing.Northwestern University.M althouse: A ssistan t P ro fesso r. to each facet, search terms are identified that capture the subject best.The groups of search terms should include a range of text words that occurs in the titles and abstracts of primary studies, as well as database subject indexes.Text words and their variants are identified when reviews and prim ary studies obtained during e a rlie r searches are read (CRD Publications Office 2001).Using the search term s 'marketing health' and 'social marketing', five articles were found during a Medline database search in Septem ber 2003.These articles are summarised in Table 3.

Table 5 : Summary of the results of Search 4
Author of various books on marketing.Expert on marketing of non-profit organisations and social marketing.Published over 100 research articles in leading journals.Received various AMA awards.Roberto: Coca-Cola Foundation. Professor in international marketing.Interests include basic marketing, social marketing and consumer behaviour.Author of seven books.Published several articles in international journals.Lee: Expert in social marketing.Held numerous corporate marketing positions.Consulted with more than 100 non-profit organisations.Participated in development of more than 50 social marketing campaign strategies for public sector agencies.Active in AMA.These authors were lecturers in the then Department of Advanced Nursing Sciences at UNISA (now the Department of Health Studies).Head of the Department of Sociology at the University of the Free State (UFS), Bloemfontein, South Africa.Fourie: Lecturer and researcher in the Department of Sociology, UFS.Focuses on the reconstruction of the South African health system.Pretorius: Lecturer in the Department of Sociology, UFS.
Perreault: Recipient of AMA Distinguished Educator Award and Academy of Marketing Science Outstanding Educator Award.Great impact on marketing research.Previous editor of Journal o f Marketing Research.Past president of AMA.McCarthy: Voted one of the 'top five' leaders in marketing; thought highly of by marketing educators.Wrote various articles and some text books on marketing.Because customers will consider both the benefits of primary healthcare services and the sacrifices/behaviour changes they have to make, registered nurses have to focus on the benefits of those serv ices for the custom er (called 'custom er v alu e' byPerreault and  McCarthy (2002:38)).

Table 12 : Summary of relation between the 4'p's (Health Sector) and the Primary Healthcare objectives
Information on the marketing of health serv ices focuses on p ro fit-se ek in g organisations and strategies used in this regard.The specific role of the registered nurse in the m ark etin g o f prim ary 22 Curationis March 2006