**4. Application of social marketing in health programs**

Gordon et al. [17] described three systematic reviews and primary studies that evaluate social marketing effectiveness. They concluded that social marketing provides a very promising framework for improving health both at the individual level and at the wider environmental and policy levels [17]. Morris and Clarkson [18] reviewed the studies using a social marketing framework for changing healthcare practice. They found social marketing as a useful solution-focused framework for systematically understanding barriers to individual behavior change and designing interventions accordingly. They argued that the social marketing approaches being adopted in public health may also provide a potent strategy for achieving change from practitioners and concluded that this approach provides a single framework to analyze and address the complex problem of behavior change, systematically using methods proven in commercial marketing [18]. Firestone et al. [19] reviewed the evidence of the effectiveness of social marketing in low- and middle-income countries, focusing on major areas of investment in global health: HIV, reproductive health, child survival, malaria, and tuberculosis. They concluded that social marketing can influence health behaviors and health outcomes in global health; however, evaluations assessing health outcomes remain comparatively limited. Evidence exists that social marketing can influence health behaviors and health outcomes [19]. Luca and Suggs [20] reviewed systematically 17 articles published after 1990. These articles reported social marketing interventions for the prevention or management of some diseases and behavioral risk factors, conducted evaluations, and met the six social marketing benchmarks' criteria. They concluded that there is an ongoing lack of use or underreporting of the use of theory in social marketing interventions and focused on applying and reporting theory to guide and evaluate interventions [20].

• Channel analysis: Identification of the best way to communicate to the target audience and know about their preferred sources of information is the main mission of channel analysis. Channels can be people, institutions, organizations, and specific communication techniques, such as mass media, personal communication, or public events. Social marketers may consider printed materials (e.g., pamphlet and brochures), printed media (e.g., newspapers and magazines), and mass media (e.g., radio and television programs, websites

During the formative research, the main ideas for intervention are determined, and primary materials develop. Before completing the production of messages and materials for implementation, it is required to pretest the key elements including methods, communications, and strategies. They are presented to some members of the target audience and receive their feedback. Modifications are made based on the feedback. Typical methods for pretesting include

Implementation is the activation of all strategies, tactics, and methods that were developed to achieve the designated goals and objectives. Activities such as the initiation of a mass-media awareness campaign, offerings of small-group self-management classes, or creation of a community coalition to improve the health behavior in a neighborhood are included in this phase.

Evaluation determines the program's success. It is done during and at the end of the intervention. When the quality of the program is assessed by documenting the extent to which it was implemented as designed, *process evaluation* has been done. In this type of evaluation, it is determined whether the program is operating as expected and whether there are areas in need of improvement. Consumer orientation, as a key concept of the social marketing process, means continually returning to the target audience and getting their reaction and point of view regarding the program. The number of self-management classes, radio programs or television advertising messages, pamphlets and brochures distributed, and posters installed in target audience neighborhoods can be the measures checked through process evaluation. The evaluation of the intervention effects, including impact evaluation and outcome evaluation, is very important in social marketing. Outcome measures could include changes in overall health status such as the mortality rate of cardiovascular diseases or prevalence rate of hypertension, while the impact measures would include improvements in health behaviors

Gordon et al. [17] described three systematic reviews and primary studies that evaluate social marketing effectiveness. They concluded that social marketing provides a very promising

contents, social networks, and mobile applications).

**3.3. Phase 5: Development**

48 Selected Issues in Global Health Communications

focus groups, interviews, and surveys.

such as smoking and physical activity [16].

**4. Application of social marketing in health programs**

**3.4. Phase 6: Implementation**

**3.5. Phase 7: Evaluation**

To obtain newer findings, we searched PubMed database using "social marketing "and found that 1655 articles have been published since 2010 till now. By limiting the search to "Systematic Reviews," 120 articles were determined, and by limiting the search more to behaviors, it showed that in 65 systematic review articles, social marketing interventions focused on behaviors. Application of social marketing to reduce tobacco use (19 articles) and alcohol consumption (18 articles), modify the nutritional practice (16 articles), promote physical activity (14 articles), and increase the condom usage (7 articles) were the most common subjects. Some particular systematic reviews in which "social marketing" has been mentioned in their titles are explained as below:

Xia et al. [21] reviewed 92 social marketing interventions published during 1997–2013. They concluded that if the six benchmarks of social marketing interventions (behavior change, consumer research, segmentation and targeting, exchange, competition, and marketing mix) are considered, and if the researchers analyze the audience, make the target behavior tangible, and promote the desired behavior, it is an effective approach in promoting physical activity among adults [21]. In another systematic review done by Luecking et al. [22], they searched PubMed, ISI Web of Science, PsycInfo, and the Cumulative Index of Nursing and Allied Health systematically to identify interventions targeting nutrition and/or physical activity behaviors of children enrolled in early care centers between 1994 and 2016. They concluded that social marketing could be an important strategy for preventing early childhood obesity through promoting physical activity and nutrition modification [22].

Aceves-Martins et al. [23] reviewed 38 non-randomized and randomized controlled trials conducted from 1990 to April 2014 in participants aged 5–17. They searched the PubMed, Cochrane, and ERIC databases to find the studies that contained social marketing strategies to reduce youth obesity in European school-based interventions. They concluded that the inclusion of at least five social marketing benchmark criteria in school-based interventions could be effective to prevent obesity in young people [23].

**6. Application of social marketing in health: some case studies in** 

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 interven-

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

tion 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**

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

Social Marketing for Health: Theoretical and Conceptual Considerations

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

**Iran**

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 multiple years could be substantial [24].

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 attitudes or behavior could not be assessed [25].

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].
