Systems Thinking in Upstream Social Marketing: Using Soft Systems Methodology to Improve Midwifery Policy in Jordan

摘要

Background: Despite being acknowledged worldwide as essential maternal care providers, midwives remain marginalized in the Jordanian healthcare system. Further, considering Jordan's goal to achieve a total fertility rate of 2.1 by 2030 and Jordanian women's preference for female providers, enhancing midwives' role could significantly promote the use of reproductive health and family planning services. Focus of the Article: We report on opportunities created by opening the boundary of our social marketing understanding to systems thinking in practice (STiP), using soft systems methodology (SSM) to engage with the complex situation of midwifery policy in Jordan. Research Question: In what ways could STiP benefit upstream social marketing interventions? We attempt to answer this question from the perspective of an SSM action research in Jordan. Program Design/Approach: The intervention combines stakeholder analysis and evidence-based policy with an SSM seven-stage cycle. We analyze the compatibility of SSM with social marketing through the NSMC's eight benchmark criteria. Importance to the Social Marketing Field: The case offers to learn experientially about the relevance of a systems' approach to complement social marketing frameworks. Drawing from the practical application of SSM, this study suggests that using systems' tools in social marketing interventions might significantly contribute to achieving intended behavioral outcomes. Methods: Gordon's alternative framework for upstream social marketing, "advocacy, relationship building and stakeholders' engagement," was enacted through the SSM's seven stages. Research findings provided advocacy arguments. Rich pictures, conceptual modeling, and the CATWOE exercise fostered relationship building and stakeholders' engagement toward the accommodation stage. Results: At the systematic level, that is, the linear chain of programmatic activities, the policy objective was achieved with an amended Law submitted to the Parliament for debate. At the systemic level, that is, the dynamic relationships among stakeholders, the social learning that emerged during the SSM process reduced policymakers' resistance and fostered their collective action. Recommendations for Research or Practice: Social marketers can benefit from further experimentation with systems' approaches to develop their STiP capabilities. Thus, social marketing practice, at this historical moment, could be better equipped conceptually and practically to manage for the emergence of positive behavior change in messy upstream situations where policy and politics are always enmeshed. Limitations: SSM calls for several iterations until stakeholders feel that no more change is needed. However, these iterations are challenging to implement during the limited time frame of development projects. In this case, another iteration was suggested to diffuse the conflict between midwives and obstetrician-gynecologists who saw themselves as victims of this policy reform. However, with Jordan Communication Advocacy and Policy ending in December 2019, this case legacy might be passed on to other projects.