**6.1. Reducing risky driving behaviors among taxi drivers in Tehran, Iran**

of at least five social marketing benchmark criteria in school-based interventions could be

Sweat et al. [24] searched the National Library of Medicine's Gateway (includes Medline and AIDSline), PsycINFO, Sociological Abstracts, CINAHL, and EMBASE to study the effectiveness of social marketing for promoting condom use. Their meta-analyses showed a positive and statistically significant effect on increasing condom use, and all individual studies showed positive trends. They concluded that the cumulative effect of condom social marketing over

Janssen et al. [25] reviewed six papers extracted through searching PubMed, PsychInfo, Cochrane, and Scopus to describe the effects of an alcohol prevention intervention developed according to one or more principles of social marketing. Based on this review, the effect of applying the principles of social marketing in alcohol prevention in changing alcohol-related

Wei et al. [26] searched the following electronic databases for results from January 1, 1980 to the search date July 14, 2010: Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, LILACS (Latin America and Brazil), PsycINFO, PubMed, Web of Science/Web of Social Science, Chinese National Knowledge Infrastructure (CNKI), and CQ VIP (China). This review provided limited evidence that multi-media social marketing campaigns can promote HIV testing among men who have sex with men (MSM) in developed countries. Future evaluations of social marketing interventions for MSM should employ more rigorous study designs. Long-term impact evaluations (changes in HIV or STI incidence over time) are also needed. Implementation research, including detailed process evaluation, is needed to identify elements of social marketing interventions that are most effective in reaching the target population and changing behaviors [26].

**1.** Social marketing is an approach to change health behaviors. It can provide a useful framework for systematically understanding barriers to and benefits of the targeted health

**2.** Social marketing programs are based on the six benchmark criteria: focusing on behavior change, consumer research, audience segmentation, exchange, competition thinking, and establishing the marketing mix or 4Ps. For applying social marketing in practice, we need some planning models that contain operational steps and constructs. The SMART model

**3.** Formative research is the heart of social marketing programs, and audience, market, and

**4.** Using social marketing to promote health behaviors is growing, but answering this question that whether the social marketing framework provides an effective means of bringing about behavior change remains an empirical question which still has to be tested in prac-

channel analysis are three fundamental components of formative research.

tice. However, many lessons have been learned in recent years.

effective to prevent obesity in young people [23].

multiple years could be substantial [24].

50 Selected Issues in Global Health Communications

products.

is one of these planning models.

attitudes or behavior could not be assessed [25].

**5. Lessons we learned from social marketing studies**

In Iran, the mortality rate due to road traffic crashes is considerably high, and risky driving behavior by road users is an important factor influencing this health problem. However, many attempts have been made to reduce risky driving behaviors; they have been limited to education and enforcement. In this study, researchers designed and implemented an intervention based on the SMART (Social Marketing Assessment and Response Tool) model to reduce two specific risky driving behaviors, tailgating and non-driving between lines, among taxi drivers in Tehran, Iran. The target audience were the professional drivers in two municipality regions with the highest rate of traffic violations as recorded by the Tehran Driving Police. Formative research inclusive of a qualitative study and a quantitative survey was designed and implemented to determine intervention components. In a qualitative study, opinions and views of 42 taxi drivers in 4 focus group discussions were explored. They talked about the current driving in Tehran, causes of risky driving behaviors, suggested practices for modification of risky driving behaviors, appropriate places for introducing products and services, and appropriate channels to communicate and influence taxi drivers. Taxi drivers believed that if they concentrate on driving, they can avoid risky driving behaviors. Most of them suggested reminding messages for drivers and using materials containing these messages. Getting help from taxi route supervisors was suggested by taxi drivers as influencing people and effective communication channels.

Based on the formative research, the social marketing-based intervention was designed. The product was the reminder message for concentrating on the avoidance of two target behaviors, and the messages containing stickers were developed and installed on the glass before the driver's eyes. In addition, developing and distributing the message containing pamphlets, and justifying taxi route supervisors as opinion leaders to communicate messages to taxi drivers, were done. After 6 weeks, two target risky driving behaviors were assessed by checklists and compared.

Before the intervention, 68.3% of drivers in the intervention group and 77.1% of drivers in the control group committed tailgating, while after the intervention, these percentages were 36.9 and 67.9% in intervention and control groups respectively. For non-driving between lines, it was similar. Before the intervention, 60.9% of drivers in the intervention group and 59.0% of drivers in the control group committed non-driving between lines, while after the intervention, these percentages were 38.9 and 52.4%, respectively. The interventions resulted in statistically significant reductions in the two target behaviors in the intervention group as compared with the control group. Furthermore, logistic regression showed that the odds ratio for avoiding tailgating and non-driving between lines increased significantly in the intervention group: 2.34 (1.30–4.21) and 1.83 (1.06–3.17), respectively [27].

#### **6.2. Using personal protective equipment (PPE) in workplaces**

Workplace injury is the second leading cause of fatal injuries in Iran. However, many programs have been implemented to reduce workplace injuries; a majority of the interventions had been designed based on viewpoints of health and industry experts and were not consumer orientated. These interventions were usually focused on education and enforcement. In other words, for people who face a choice with attractive alternatives, or barriers, a third approach is needed; there was not any solution. In this study, an intervention based on the SMART model was designed and implemented to persuade workers in two constructing subway stations to use personal protective equipment (PPE) at the workplaces in Isfahan, Iran. This study is a quasi-experimental intervention based on the SMART model. A total of 44 employees in two separate subway stations under construction in Isfahan were assigned into intervention and control groups. All constructing subway stations were listed and one of them was selected as an intervention station randomly. By considering the similarities in the number and composition of employees in all stations, another one was considered as the control station. Intervention and control stations were in the north and center regions of Isfahan, respectively. Formative research included a qualitative study and a quantitative survey was designed. In the qualitative study, focus group discussions (FGDs) were used to explore viewpoints of the audience about PPE usage. The participants were asked to talk about the importance of using PPE, factors that influence their use and strategies to increase the use of PPE. In the quantitative study, attitudes and self-reported behaviors were measured by a 28-item questionnaire. Workers in both intervention and control stations completed the questionnaires and a 10-item checklist was used by two trained observers to record observed behaviors regarding PPE use. Based on initial findings, a free package containing a well-designed light-weighted helmet, a dust mask and safety gloves were delivered to workers in the intervention group. A sticker with an emotionally tailored message reminding them of the importance of caring for themselves because of their families was attached to the helmet. This message was developed based on concerns expressed by the workers during FGDs. They had told that their families were the most important reason for using PPE because injuries would result in problems not only for themselves but also for their families. Providing and delivering a free and suitable package containing PPE in the workplace and promoting the product through personal communication and applying printed materials were its main components. The intervention was done in the workplace, and stickers with the message "I take care of myself because of my family" were attached to all helmets. In the package, we also put a simple tailored pamphlet including messages related to the advantages of using PPE and the risks they can reduce. For people who were unschooled, face-to-face counseling was held. The intervention was implemented for 4 weeks in the intervention station. Engineers and foremen supervised the use of PPE and reminded and warned the employees to use the package content. After 6 weeks, the use of PPE in both intervention and control stations were checked by checklists. Behaviors in the intervention and control stations were measured using an observational checklist. After the intervention, the percentage of workers who used PPE at the intervention station increased significantly. Before the intervention, none of the workers in intervention station used helmet and safety masks, and 4 and 12% of them in the control station used these PPEs. After the intervention, 43.5% of the intervention group and 27.3% of the control group used helmets, and 39.1% of the intervention group and 18.2% of the control group used safety masks and these percentages were 36.9 and 67.9% in intervention and control groups respectively. The intervention resulted in statistically significant reductions in the two target behaviors in the intervention group as compared with the control group [28].

**6.3. Promoting mammography in Iranian women**

comparison group [29].

significant change [30].

**6.4. Promoting normal vaginal delivery**

Mammography has an important role in early detection of breast cancer. So, the health sector tries to persuade women to do that. A majority of the interventions are based on education and information and there has been less attention to making mammography cost beneficent. This study aimed at assessing the effect of a social marketing-based intervention to persuade one to do mammography in Bojnord, Iran. In this study, two villages which had similar demographic characteristics such as population, sex ration, and socioeconomic status, considered as intervention and comparison groups randomly. All women of 35 years and older consisted of 343 women (151 in intervention and 191 in comparison groups) and were included in the study. To obtain the main idea for intervention, and exploring the viewpoints of the target group about mammography, a formative research combined of a quantitative survey and a qualitative study was done. It was completed by the women to assess their attitudes, and four focus group discussions were established to gather qualitative data. The quantitative study showed that time for referring and waiting in hospitals, financial costs, forgetting mammography, and fear of exposure to x-ray are more prominent. In the qualitative study, expending time and high economical costs are considered as two main factors related to not taking up mammography. According to the formative research findings, an intervention focused on the main barriers that were designed. Women who chose mammography were registered in health houses. After arranging the appointments with the local hospital, women were picked up in groups and brought to the hospital. A person who was familiar with the process of mammography welcomed them and coordinated the service. Mammography was not free, but a significant discount had been considered by the hospital. This program was implemented for 4 consecutive weeks. One week after the intervention, the number of mammograms in two villages was determined and compared. After the intervention, 48.1% of the women in the intervention group went for mammography and there were no changes in the

Social Marketing for Health: Theoretical and Conceptual Considerations

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The rate of Cesarean sections in Iran is higher than the acceptable rate recommended by the World Health Organization. Regardless of implementing many educational programs to reduce Cesarean section rates, some barriers are influencing the choices of pregnant women. This field trial was done in Yasuj, Iran, and 39 3–4 months pregnant primigravida were included in the study as the target audience. They chose Cesarean section for delivery. A formative research combined of a quantitative survey and a qualitative study was done to achieve the social marketing mix, and based on the results a tailored intervention was designed and pretested on the subjects. The product was a promoting package that consisted of a short-time instruction, messages for brief interventions in public health facilities, and a phone counseling service managed by trained midwives. The final intervention was implemented for a period of 1 month and its effectiveness was assessed after at least 1 month by a proportion test. One month after the intervention 30 pregnant women expressed willingness and intentions to have a normal delivery, which was a statistically
