Inuence Of Marketing Mix On Adolescents’ Voluntary HIV Testing Uptake In Tanzania: Experience From Physical Evidence

Background In public health, traditional 4Ps (product, price, place and promotion) of the marketing mix have been successfully used to inuence clients/patients to adopt desired health behaviors and health status changes in reproductive health, tuberculosis (TB), malaria, child survival and human immuno-virus (HIV) interventions. However, the use of additional 3Ps (Physical evidence, People and Process) of the marketing mix have rarely been used in public health interventions. This study examined the inuence of physical evidence on voluntary counseling and testing (VCT) uptake among adolescents in Tanzania. Methods A cross-sectional study design using quantitative method was conducted in Dodoma. A multi-stage random sampling method was used to select nine secondary schools and 449 study participants. Self-administered structured questionnaire was used. Data was analyzed using SPSS v17. Relationship between independent and dependent variables was analyzed using binary logistic regression and correlation analysis with p-value of (cid:0) 0.5 regarded as signicant. Binary logistic regression was used to determine predictors of VCT uptake. Descriptive statistics was used to analyze participants’ characteristics and ranking of physical evidence variables’ on VCT uptake among adolescents. Results Of 449 study participants, 54% and 46% were females and males respectively. The participants’ age range was 12–19 years. 96% of respondents had knowledge of VCT, 90.6% were willing to test for HIV, however; 78% had not tested for HIV. Physical evidence variable modern equipment was highly ranked inuential variable regarding VCT uptake. Independent variables modern equipment, physical facility, personnel and materials were found predictors of VCT uptake. Participant characteristics age and school type were also predictors for VCT uptake. VCT and service marketing mix. Questions on physical evidence adopted and modied from standardized Servqual questionnaire, considering service quality dimension and service marketing model.


Background
Since the onset of HIV / AIDs in the world , 71 million people have been infected with HIV. Of which, adolescents (10-19 years) and young(1) people (15-24 years) represent key population that is highly affected by HIV (2). In Tanzania, HIV remains to be one of the main national health priorities, since in 2016, about 1.4 million people lived with HIV(1). The HIV infection causes a negative impact to effected communities through loss of the most productive segment of the society leading into economic decline to affected countries (3,4).Efforts have been done globally and at national levels to combat HIV / AIDs pandemic, including establishment of 90-90-90 targets to AIDS epidemic by 2020, which emphasizes on 90% of people living with HIV (PLHIV) to know their HIV status by year 2020 (5). This led to strengthening of VCT strategies globally, since VCT is regarded as one of the important components of HIV prevention, treatment, care and support (6). It is potentially effective and affordable method of preventing HIV infection in developing countries.
Despite all these efforts, VCT uptake has been low. Example,by the end of 2014 there were still 17 million people out of 37 million people who were living with HIV who had not tested for HIV (5). In Tanzania alone, testing rates in 2012 was 35.4% (7), while in 2014 was 28.4% (8). Among adolescents, 65.8% male and 43% female of 15-24 years had never tested for HIV (7).The reason for low uptake of VCT remains unclear.
In Public health, health promotion strategy has been the main approach used in implementation of public health interventions (9). Whereas in business, marketers have been working towards changing perceptions of their customers towards their services and products through working on the marketing mix elements, the 4Ps (product, price, place and promotion) (10). Because of the inherent intangibility and nature of the service, the additional three Ps i.e physical evidence, process and people were introduced (11). The new components are important in service promotion in the eyes of the customers. It is agreed that there is variation in customer perception between individuals, which has great impact on buying decisions (12).
Marketers work on controlling elements of the marketing mix i.e product, price, place, promotion, people, process, physical evidence to change customer perception in order to in uence buying decisions (11).
Through the concept of social marketing, marketing concepts have been adopted in public health interventions to in uence desired behavioral change (13), giving positive results. Example, in a study conducted in Cameroon to assess the impact of condom use among youth aged 15-24, when market mix elements, the 4Ps i.e product, price, promotion and place were integrated in the intervention condom use among adolescents increased (14). Therefore, there is the need to assess the in uence of the additional 3Ps i.e people, process and physical evidence on public health interventions. Therefore, this study aimed at determining the in uence of physical evidence on VCT uptake among adolescents in Tanzania. Adolescent are among the most risk groups for contracting HIV infection and highly underrepresented among VCT clients (15).

Research design
The study used cross-sectional study design together with quantitative method to determine the physical evidence of VCT uptake.

Study area
The study was conducted in Dodoma city, which is part of the seven districts in Dodoma Region. The city has four divisions, 41 wards and 51 secondary schools of which 36 are public secondary schools and 15 private secondary schools with a total of 23,231 in all secondary schools (16). The reason of choosing Dodoma region was because it has recently become a city, which has resulted to an in ux of people from different parts of the country. This may contribute to increasing risk of HIV infection.

Study population
The target population was secondary school students in Dodoma city who were enrolled in Government schools. Participants were given the chance to decide on whether to be in the study or not. For those participants who decided not to participate they were discontinued at the earliest stage of recruitment.

Sample size
The sample size of 391 was obtained by using Yamane sample calculation formulae. Where population size "N" was 19,200; margin of error 0.05, con dence interval 95%. However, a convenient sample size of 500 was used.

Sampling method
A multi-stage systematic random sampling procedure was used to identify government secondary schools and study participants.
Stage 1 was for identi cation of secondary schools. A list of 36 public secondary schools arranged in ascending order of their names was created. Based on number of schools required, which was nine, 36 schools were divided by nine to get n th value equal to four. Then the rst school was randomly selected by lottery method, followed by selection of every fourth school starting from the rst selected school.
Stage 2 was identi cation of classes through strati cation method. For every secondary school strati cation was based on number of classes, since other schools had form I-IV, while others form I-VI. Stage 3 strati ed the classes further based on gender for purpose of equal presentation among females and males. Eventually, the study participants were selected through systematic random selection within each stratum. Within each stratum, sampling interval was calculated based on the required sample size for each stratum. Population size within the stratum was divided by required sample size to get the sample interval. The list of students in ascending order based on their names was created for each stratum. Starting participant was selected randomly by lottery method. Using the calculated sampling interval, every "n th " student from the rst student was selected to participate in the study.

Data collection
A self-administered structured questionnaire in both English and Kiswahili was developed. The questionnaire comprised of four sections. Section I related to background information, Section II on knowledge of HIV/VCT services, Section III on uptake of VCT services and Section IV on service quality dimension and service marketing mix. Questions on physical evidence adopted and modi ed from standardized Servqual questionnaire, considering service quality dimension and service marketing model.
In this model, service quality model is classi ed according to the three service marketing elements physical evidence, people and process (17).

Validity and Reliability
To ensure validity and reliability of the research tools, pretesting of the Swahili questionnaire was done using a convenient sample of 26 (13 females and 13 males). Needful phrasing adjustments particularly on physical evidence variable questions were done.

Study variables
The study had one dependent variable, VCT uptake and four independent variables. The independent variables include modern equipment, physical facility, personnel and material. In uence of independent variables on VCT uptake was determined by asking participants the level of in uence an independent variable has on VCT uptake using a ve-point Likert Scale questions.

Data management and analysis
Data collected was coded into computer, cleaned, validated and eventually analyzed using statistical package for social sciences (SPSS) version 17. Descriptive statistics was used to analyze participants' characteristics, VCT uptake among participants and ranking of physical evidence variables. Binary logistic regression analyzed the association between independent and dependent variables, using odds ratio and P-value 0.5. Correlation analysis analyzed association between independent and dependent variables with level of signi cance P value 0.5.

Ethical consideration
Before the study took place, it was reviewed by the Ethical Review Committee of the University of Dodoma. Study participants consent was considered before engaged in the study. Participants were introduced about the study, they were given time to ask questions in a frank and friendly way. Upon participant's discretion, he/she was given opportunity to decide on whether to participate or not in the study. Participants' information was secured.

Response rate
Out of 500 study participants, only 449 participants participated in the study giving a response rate of 89.8% Participants' characteristics Table 1 shows that among 449 participants, 54% were females and 46% male. The age distribution of participants ranged from 12 to 19 years, with majority of participants being 16-18 years (61%). Almost half of participants were from Form III and IV, with majority being Christians (73%) and day scholars (76%). Most of the participants had heard about the VCT service (93%) and had proper knowledge about the VCT service (96%).  Descriptive statistics on relationship between the service marketing mix element, physical evidence and VCT uptake Table 3 shows that physical evidence variables, modern looking equipment and appealing physical facilities were highly ranked priorities that could in uence adolescents' VCT uptake.  contribute to the VCT uptake among adolescents. It further means that, any attempt to improve modern equipment among those who agree and strongly agree will increase the VCT uptake among adolescents.
On the other hand, the ndings show that, the chances of up taking VCT is 5% (1.055) and 98% (1.982) among those who agree and strongly agree respectively. These ndings are demonstrated in Table 5.

Correlation analysis between modern equipment and VCT uptake among adolescents
Pearson correlation analysis between modern equipment and VCT uptake among adolescents shows a positive correlation of 0.518 and signi cant value of 0.007 indicating that, increases in modern equipment means increasing VCT uptake among adolescents as shown in Table 6.
Physical facility and VCT uptake among adolescents Physical facility was found to have signi cant relationship with 'agree' and 'strongly agree' categories with beta and p values of 1.295, 0.022 and 1.115, 0.007 respectively. This means that, those who agreed with physical facility had high odds of 1.745 (75%) and 1.891 (89%) of up-taking VCT than those who responded with disagree, which is shown in Table 5.

Correlation analysis between physical facilityand VCT uptake among adolescents
Pearson correlation analysis between physical facilities and VCT uptake among adolescents shows a positive correlation of 0.666 with p value of 0.016 indicating that, increases in physical facilities means increasing VCT uptake among adolescents.

Personnel and VCT uptake among adolescents
Personnel of the staff was another variable which was found to have likelihood of 1.531 (53%) and 1.523 (52%) for agree and strongly agree responses respectively on up-taking VCT than those who responded with disagree. This means that, the variable is determinant as it is signi cant with 0.011 and 0.029 p values respectively. On the other hand, the variable was found to have positive correlations for neutral, agree and strongly agree responses as shown in Table 5.

Correlation analysis between personnel and VCT uptake among adolescents
Pearson correlation analysis between personnel and VCT uptake among adolescents shows a positive correlation of 0.424 with p value of 0.012 indicating that, improvement in personnel will improve VCT uptake among adolescents. The details are shown in Table 6.
Material and VCT uptake among adolescents As shown in Table 5, materials evidence was analyzed to have a direct and signi cant correlation with VCT up -taking. The results show that, the likelihood of up taking VCT with respect to material is 225 with p value of 0.002 for strongly agree response and likelihood of 217 with p value of 0.016 for agree response. This means that, improving material will positively increase up taking of VCT by 1. 829 and 2.923 for strongly agree and agree responses respectively compared tothose who responded as disagree.

Correlation analysis between material and VCT uptake among adolescents
The results in Pearson correlation analysis between material and VCT uptake among adolescents shows a positive correlation of 0.381 with p value of 0.036 indicating that, improvement of materials in the hospital will signi cantly improve VCT uptake among adolescents.
Results of the ndings revealed that, generally, physical evidencecontributes signi cantly to the VCT uptake among adolescents as shown in Table 6.

Discussion
Despite the fact that most of adolescents had knowledge of HIV (95%)and were willing to test for HIV (90%), very few had tested for HIV (22%).Similar ndings were observed in a study conducted in Arusha Tanzania (18). However, an Ethiopian study showed higher VCT uptake among adolescents (19). This could be due to differing socio-cultural characteristics and beliefs between countries. There is an indication that knowledge and willingness alone are not enough to in uence adolescents to uptake VCT.
Among the seven respondent characteristics (sex, age, education, religion, type of school, awareness and knowledge of VCT), only two characteristics which are age and school type are predictors for VCT uptake among adolescents. This is contrary to a study in Arusha that showed sex, age, education level and religion as predictors (18). The difference could be attributed to differing contextual environment that may in uence their behaviors. For age, adolescents 18 years and above had higher chances of VCT uptake, which is similar to a study conducted by Sanga et. al., (18).
Variation on adolescents' expectations on physical evidence variables concerning to VCT uptake was observed, with higher expectationson modern equipments and physical facility that are attractive or appealing. This indicates that individuals have different service expectations, which when met may lead to client satisfaction and increase service utilization or uptake (20,21). Understanding of clients' expectations and needs is important step towards delivering of high quality service (22,23)that meets clients' satisfaction.
Physical evidence was observed to have a signi cant in uence on VCT uptake. Presence of modern looking equipments in healthcare facilities have shown to have signi cant in uence on VCT uptake among adolescents. Similar ndings were observed in other studies (24).
Presence of physical facilities which are visually appealing have shown to have signi cant in uence on VCT uptake among adolescents. Angoodet. Al., went further to comment on importance of a welldesigned physical healthcare facility that is attractive to patients/clients (25).
Chaipoopirutanaet. Al., showed that signs, artifacts, amenities and symbol are other important components of physical evidence (26).
Neat appearance of personnel signi cantly in uences VCT uptake among adolescents. Jager and Plooy also had similar ndings that support personnel neatness in healthcare facilities (24).
Presence of visual appealing materials related with service (such as statements orpamphlets) and equipments have shown signi cant in uence on VCT uptake. This was supported by Jagerand Plooy study (24).

Study Limitation
The study used questionnaire to collect data, which predisposed the study participants to information bias. Participants could likely interpret differently the questions, thus providing wrong responses.
Moreover, the study was limited to adolescents who are attending secondary school, therefore the information may not re ect the opinions of out of school adolescents.

Conclusion
Despite majority of adolescents had knowledge on VCT service and were willing to test for HIV, VCT uptake was low. Meaning that knowledge and willingness a lone are not enough to in uence VCT uptake. Moreover, age and school type are predictors of adolescents' VCT uptake. Examination on in uence of physical evidence of the service marketing mix elements on VCT uptake among adolescents revealed that physical evidence has signi cant in uence on adolescents' VCT uptake.
Therefore, there is a need for Public Health managers and policy makers to integrate the physical evidence in public health interventions in order to increase VCT uptake among adolescents in Tanzania. Emphasis should be put to ensure that healthcare facilities have modern looking equipments, physical facilities that are visually attractive, healthcare workers who are neat and appealing, and service materials that are visually attractive in order to attract adolescents to uptake VCT.