Social Marketing Assessment and Response Tool (SMART) Model
The SMART model was used in this study, whose phases are preliminary planning; audience, channel, and market analysis, educational materials development, pretesting, implementation, and evaluation (21). The preliminary planning phase was done by identifying the problem and reviewing the resources available to the research team. Social marketing programs are dominantly based on conducting formative research to design interventions to ensure proper responses to the demands and needs of the target audience (22). The formative research consists of audience analysis, market analysis, and channel analysis, conducted in this study in the form of a qualitative study (focus group discussions and in-depth semi-structured interviews). The views and comments of the target group and experts involved in HIV/AIDS programs on promoting HIV test, elements of behavior marketing, appropriate and effective communication channels and initial ideas for intervention were identified during this formative study.
Study Design And Setting
This study was a quasi-experimental pretest-posttest without a control group. The study comprised a qualitative study to achieve an intervention content and structure, implementation, and evaluation phases. The study was carried out in Boyer-Ahmad County, southwest of Iran, in 2019.
Qualitative Study
The qualitative study based on the content analysis approach aimed to determine the content and structure of the intervention. The qualitative data was collected by applying focus group discussions (FGD) with members of the target community and in-depth semi-structured interviews with health care providers involved in HIV/AIDS programs. The following semi-structured questions were used to collect qualitative data in FGD. These questions were designed according to the aim of the study and the principle of formative research in the social marketing approach.
What do you think is important about early detection of HIV infection?
What do you think are the reasons for low referrals to do HIV test?
If people want to get tested for HIV, where are the right places?
When is the best time for people to come in for HIV test?
What channels can be used to encourage people to get tested for HIV?
What can be done to persuade people to get tested for HIV?
Semi-structured questions of the in-depth interviews were as follow:
What do you think are the reasons for the low number of people coming for an HIV test in Boyer-Ahmad county?
In your opinion, what are the obstacles for the residents of Boyer-Ahmad city to go for an HIV test?
What do you think are the best communication channels with people to encourage them to get tested for HIV?
What are your suggested ways to persuade people to come in for an HIV test?
Inclusion criteria included people aged 21 to 35 living in Boyer-Ahmad county who had informed written consent to participate in the study. The exclusion criteria were unwillingness to continue to participate in the study for any reason.
For the FGD, the participants were purposefully selected and divided into four groups considering their age (21–35 years old), sex (male and female), level of education (having or not having a university degree (and place of residence (rural and urban). The number of individuals in each group was 8–12 people. It should be noted that the reason for selecting the participants from the age group of 21–35 years was that 51% of HIV/AIDS patients are in this age group (9).
To invite the participants to attend the FGD sessions, the researcher referred to Akbarabad Healthcare Center and Mehriyan Healthcare Center and obtained participants’ information considering the mentioned variables from SIB-Integrated Health Record System and then called these individuals. A total of four FGD sessions were thus held with 42 members of the target community. Further sessions were not required due to data saturation and duplication of opinions and content. Each FGD session lasted about 90 minutes. At the end of the sessions, the conversations recorded by the researcher were also transcribed and then compared with the notes taken. Ultimately, the final draft of the transcriptions was formulated and it was prepared for content analysis.
In another section of the formative research that included in-depth semi-structured interviews with health care providers involved in the HIV/AIDS Program, the first author referred to their workplace and introduced herself, explained research objectives, and invited them to interviews. Upon showing willingness, the time and the place of the interviews were set. Each interview took an average of 60 minutes. Before each interview, the researcher introduced herself and the study and then requested the participants to sign the consent forms. Concerning the consent of each participant, the interviews were recorded by a voice recorder. Then, they were transcribed and the final draft was prepared for manual qualitative content analysis.
Qualitative data were analyzed manually by content analysis method using a concurrent analysis approach. First, the audio files were converted to text files. These files were carefully read several times by the researcher to gain a general understanding of the text, and the sentences that answered the questions were identified. Then in each of these sentences, the main concepts were given a theme. In the next step, these themes were compared with each other to determine the main and sub-themes. Then the main themes and sub-themes were carefully read several times so that the main themes with similar meanings were placed in a category and formed classes.
Intervention Phase
Based on the qualitative results, the main content was developed for the campaign and then the slogan and the message were designed. According to the findings of the qualitative study and the aim of the study, “Test, the only method to diagnose HIV”, was defined as a slogan and “HIV test; fast, free, and confidential with professional Consultation; test now” consider as the camping message.
After that, the camping materials such as banners, posters, pamphlets, referral forms, and short messages were designed, pretested, and reformed. The campaign was implemented in Boyer-Ahmad County for one month in October 2019. The components of the campaign included the following:
Composing and sending SMS
At this stage, according to the qualitative results, the content of the SMS was composed, pretested, and revised by the research team and target grout, and then it was sent to 15,625 individuals of the target community via the Telecommunication Company of Iran (TCI). The content of the SMS included the slogan, the message of the campaign, and the address of the testing health facilities centers.
Preparing and installing banners
At this stage, 10 pre-designed 200×90 standard stand banners were distributed and installed in the healthcare centers at Boyer-Ahmad County, the campus of Yasuj University of Medical Sciences, and dental clinics.
Installing posters at the target community’s gathering places and distributing pamphlets among them
At this stage, 100 posters were printed and installed at the target community’s gathering places including universities, dormitories, offices, and dental clinics. At the same time, 300 pamphlets were printed and distributed among these groups for further explanation of HIV/AIDS and its modes of transmission, diagnosis methods, and introduction of testing places. To do this, the researcher first explained the campaign and its objectives by referring to the Vice-Chancellor’s Office for Cultural Affairs of Universities, Public Relations Department of offices, dental clinics, and doctors’ offices, and installed posters and pamphlets upon receiving permits. The researcher also sent them an electronic version of the campaign materials by creating a contact list in the WhatsApp Messenger group of cultural officials of universities, student associations, university unions, and public relations departments. Simultaneously, the researcher also visited all off-campus dormitories in Boyer-Ahmad County, distributed the posters and pamphlets among them, and received the telephone numbers of the dormitory administrators to send them electronic versions of the campaign materials and program messages.
Posting campaign messages on social media and provincial websites
In addition to the initial SMS sent to subscribers through the TCI, a message was sent to the target community daily via social networks and cyberspace. So, the SMS content was composed daily by the researcher and sent through the contact list of groups of student associations, university unions, class groups, and public relations departments on WhatsApp Messenger and the pages of the Vice-Chancellor’s Office for Cultural Affairs and the university union on Instagram. At the same time, the newsletter entitled “Promotion of HIV testing” was prepared by the researcher and submitted to local news websites of Boyer-Ahmad Country to publish.
Distributing the referral forms at the CBHCS
The research team decided to distribute the referral forms in the Family Health Unit of Shahid Ashrafi Healthcare Center, responsible for holding pre-marriage counseling programs. To this end, the researcher explained the objectives of the campaign to the individuals in charge of holding the programs by visiting Shahid Ashrafi Healthcare Center and asked them to discuss HIV/AIDS and how to diagnose it as well as the importance of its early diagnosis, together with their main topics. They were also urged to encourage couples to have HIV testing, and if they wish, complete referral forms, and attend the CBHCS. It should be noted that the referral forms were simply designed to encourage couples to do HIV testing but not a kind of coercion.
Publicizing campaign message on local TV stations
Following the suggestions raised by the study samples in the formative research, in which the TV show entitled “Dena Nights” had been selected as a popular and appropriate program for conveying campaign messages, the researcher made arrangements with the Vice-Chancellor’s Office for Health to send a letter to the Islamic Republic of Iran Broadcasting (IRIB) and ask them to devote a TV program to this campaign concerning commandment to apportion 5% of IRIB programs to health issues. After coordinating with the director of the given program, it was decided to allocate one program to the campaign, but it was canceled due to some problems.
Establishing and operating a mobile health center in Boyer-Ahmad County to give information about educational services, and HIV testing in high-risk areas
This program was canceled due to two serious problems including a lack of rapid test kits and the HIV/AIDS epidemic incident that occurred in Chenar Mahmoudi village in Lordegan County and no preparation by the target community to visit this center for testing. To determine the effectiveness of the campaign, data on the number of people referred to the Behavioral Diseases Counseling Center for HIV testing were collected three months before the campaign and two months after the campaign. The province's comprehensive electronic HIV/AIDS data management system was used to determine the number of people who were referred to the Behavioral Diseases Counseling Center for HIV testing.