Downloaded from http://injuryprevention.bmj.com/ on November 14, 2015 - Published by group.bmj.com
IP Online First, published on April 14, 2015 as 10.1136/injuryprev-2014-041461 Brief report
Persuasion to use personal protective equipment in constructing subway stations: application of social marketing Mahmoud Shamsi,1 Abbas Pariani,2 Mohsen Shams,3 Marzieh Soleymani-nejad4,5 1
Industrial Engineering, Systems Management and Productivity, Isfahan, Iran 2 Center for Control of NonCommunicable Diseases, Deputy of Health, Ministry of Health and Medical Education, Tehran, Iran 3 Social Determinants of Health Research Center, Yasuj University of Medical Sciences, Yasuj, Iran 4 School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran 5 Department of Nursing, Masjed-Soleiman Branch, Islamic Azad University, Masjed-Soleiman, Iran Correspondence to Dr Mohsen Shams, Social Determinants of Health Research Center, Yasuj University of Medical Sciences, Yasuj, Iran; [email protected] Received 15 October 2014 Revised 17 March 2015 Accepted 20 March 2015
To cite: Shamsi M, Pariani A, Shams M, et al. Inj Prev Published Online First: [ please include Day Month Year] doi:10.1136/ injuryprev-2014-041461
ABSTRACT To study the effects of an intervention based on social marketing to persuade workers to use personal protective equipment (PPE) in constructing subway stations in Isfahan, Iran. This was a quasi-experimental study. Two stations were selected as intervention and control groups. Intervention was designed based on results of a formative research. A free package containing a safety helmet with a tailored message affixed to it, mask and gloves and an educational pamphlet was delivered to the intervention group. After 6 weeks, behaviours 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. OR for helmet and mask usage was 7.009 and 2.235, respectively, in the intervention group. Social marketing can be used to persuade workers to use PPE in the workplace.
INTRODUCTION Using personal protective equipment (PPE) as a specialised clothing or equipment worn by an employee for protection is a best practice strategy for reducing occupational injuries.1 In Iran, workplace injuries are the second leading cause of fatal injuries,2 and the reasons for more than 88% of these injuries are not using PPE, not adhering to safety rules and carelessness.2 According to official statistics, mortality rate due to workplace injuries increased 18.8% in the first 6 months of 2010 compared with the same time of 2009,3 and proximate causes of these injuries were lack of guards for instruments and devices, poor quality of tools and devices, carelessness, failure to follow safety rules and crowded equipment in workplaces.3 Failure to use PPE or incorrect usage of PPE is responsible for more than 28% of unsafe behaviours in Iranian workplaces.4 Provision of PPE and its use by construction workers is addressed in Iranian work law.5 Construction industry workers are faced with many occupational injuries and hazards. So, they should use helmet and gloves for preventing head and hand trauma, and dust mask for preventing inhalation of dust and particles. But there are some obstacles to the use of PPE, such as poor quality of equipment, lack of worker education or motivation for its use and lack of a common perception between workers and employers about usefulness of equipments.6 To facilitate individual-based changes or community-based changes, health education alone is insufficient, and marketing concepts must be
applied with a stronger consumer orientation. Identifying the wants and needs of the target audience, as well as the challenges, likes, dislikes and fears related to a health problem and its determinants, is known as consumer analysis by Neiger in the Social Marketing Assessment and Response Tool (SMART) model, as consumer orientation by Lefebvre and Flora and as formative research by Bryant.7 Learning about demographic, psychosocial and behavioural variables through qualitative and quantitative methods is necessary for segmenting the primary general target audience into smaller and more homogenous subgroups and developing the particular interventions needed to modify risky behaviours. In this way, a more effective intervention can be designed and implemented.8 The main question is how we can increase the use of PPE and change workers’ current behaviours in workplaces. Social marketing, defined as “using commercial marketing concepts and techniques for selling an idea or behavior to people”,9 is an approach for changing behaviours that can be used for increasing use of PPE. Social marketing bridges the gap between education and enforcement and is a good solution for those who are aware of the need to change behaviour but have not considered changing it.8 Exchange theory views consumers as acting primarily out of self-interest as they seek ways to optimise value by doing what gives them the greatest benefit for the least cost. This theory reminds social marketers that they must (a) offer benefits that the consumer (not the public health professional) truly values; (b) recognise that consumers often pay intangible costs, such as time and psychic discomfort associated with changing behaviours and (c) acknowledge that everyone involved in the exchange, including intermediaries, must receive valued benefits in return for their efforts.10 It attempts to influence voluntary behaviour by offering or reinforcing incentives and/or consequences in an environment that invites voluntary participation.11 So, it will be useful for the majority of workers who are aware about PPE but do not want to use them while working. In public health, there are some models for applying social marketing in practice. SMART model, developed by Neiger in 1998, is one of these frameworks. In SMART model, intervention is designed based on the findings of a three-step formative research, including consumer analysis, market analysis and channel analysis.12 13 In this study, an intervention based on the SMART model was designed and implemented to persuade workers in two constructing subway stations to use PPE at the workplaces.
Shamsi M, et al. Inj Prev 2015;0:1–4. doi:10.1136/injuryprev-2014-041461
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from http://injuryprevention.bmj.com/ on November 14, 2015 - Published by group.bmj.com
Brief report METHOD This study is a quasi-experimental intervention based on the SMART model. Forty-four employees in two separate subway stations under construction in Isfahan were assigned as intervention and control groups. All constructing subway stations were listed and one of them was selected as intervention station randomly. By considering the similarities in the number and composition of employees in all stations, another one was considered as control station. Intervention and control stations were in north region and centre region of Isfahan, respectively. So, two stations were far from each other and had no relationship. We needed to do formative research to analyse audience, market and channels. So, a qualitative study and a quantitative study were designed. In the qualitative study, focus group discussion (FGD) was used to gather data. A focus group with 11 participants was formed to explore viewpoints of the audience about PPE usage. The participants were selected randomly from both sites. During FGD, we asked the participants to talk about importance of using PPE, factors that influence their use and strategies to increase the use of PPE. The session was held in one of the stations, with the corresponding author as coordinator. Informed consent was obtained from all participants. Two trained note takers attended the session and wrote and taped the discussion. Immediately after the session, the tape and notes were reviewed and main themes were extracted. In the quantitative study, attitudes and self-reported behaviours were measured by a 28-item questionnaire. In this questionnaire, we asked 13 attitude questions with five-level Likert items (from ‘strongly agree’ to ‘strongly disagree’) and seven self-reported behaviour questions with four-level items (from ‘always’ to ‘never’). Workers in both intervention and control stations received the questionnaire and wrote their answers on it. For recording observed behaviours regarding PPE use, a 10-item checklist was used by two trained observers directly. Both tools were developed by the researchers and reviewed by content experts. Data collection was done for 5 days. Based on initial findings, a free package containing a welldesigned light-weighted helmet, a dust mask and safety gloves was delivered to workers in the intervention group. A sticker with an emotionally tailored message reminding them of the importance of caring themselves because of their families was attached to the helmet. This message was developed based on concerns expressed by the workers during FGD. They had told that ‘their families’ were the most important reason for using PPE because injuries would result in problems for their wives and children. In social marketing approach, considering ‘marketing mix’ or 4Ps ( product, price, place and promotion) is fundamental. We considered marketing mix completely. Providing and delivering a free and suitable package containing PPE in workplace and promoting the product by personal communication and applying printed materials were its main components. The intervention was done in the workplace, and stickers with 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 advantages of using PPE and the risks they can reduce. For people who were unschooled, face-to-face counselling 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, we observed the use of PPE in both intervention and control stations using checklists. Paired and independent t tests, χ2 and linear regression were used to 2
analyse the data. The members of the control station received the same package after the evaluation.
RESULTS In FGD, six participants (54.5%) were under 35 years old, literacy level of seven participants (63.6%) was under grade 12 and seven participants (63.6%) had at least 7 years of working history. Most participants believed that PPE ‘protected them against injuries’. Almost all declared it is necessary to use PPE while working. When they were asked about reasons for not using PPE in workplace, participants mentioned some barriers. These included: A helmet interferes with my work and I can’t work easily with it It’s difficult to breath with mask Gloves do nothing for me for serious injury. They just prevent minor wounds which are not important When I work at heights, my helmet falls down.
Some participants also mentioned heaviness, an uncomfortable strap under the chin and reduced proficiency due to helmet use. Some participants said it is difficult to use a helmet in the summer because of excessive warmth. Some believed that PPE is just for certain conditions. These are their quotations: Helmets are just for inside, why do we have to use them outside? I certainly use gloves when carrying beams and pipes, I use masks when there is dust, but why should I use it if there is no dust? I use gloves to protect my hands just in the summer when pipes are hot.
Some participants also mentioned that they would not pay for PPE but would use it if provided by the company, although others stated they would be willing to buy PPE themselves if they were not expensive. Participants had different viewpoints about strategies to increase the use of PPE. Financial support for those who use the equipment, enforcing its usage through worksite supervision (close and remote) and continuing education about the importance of PPE were some of these ideas. Another interesting idea was assigning someone as safety supervisor to notify workers who don’t use PPE. Of all 44 participants, 23 workers (52.2%) were in the intervention group and 21 workers (47.8%) were in the control group. These groups had no significant differences in demographic variables such as age, daily work hours, literacy level and work history. The mean and SD for scores of attitude and self-reported questionnaire and behaviour checklist can be seen in table 1. These findings show that most participants know about the necessity and benefits of using PPE. Participants reported their use of PPE to be good. However, scores of self-reported
Table 1 Attitude, self-reported behaviour and observed behaviour among workers in two stations before the intervention
Attitude Self-reported behaviour Observed behaviour
Score range
Mean (SD)
13–65 7–28 0–10
50.50 (5.69) 15 (4.74) 4 (1.64)
Shamsi M, et al. Inj Prev 2015;0:1–4. doi:10.1136/injuryprev-2014-041461
Downloaded from http://injuryprevention.bmj.com/ on November 14, 2015 - Published by group.bmj.com
Brief report Table 2 Percent of observed behaviours before the intervention Answers
Table 4 workers
OR for using personal protective equipment (PPE) among
Items
Yes (%)
No (%)
Behaviour of using PPE
Used safety shoes while working Used safety clothes while working Used helmet while working Used safety mask while working Used safety gloves while working
68 22 2 6 82
32 78 98 94 18
Helmet Time Before intervention After intervention Group Control group Intervention group Group×time Safety mask Time Before intervention After intervention Group Control group Intervention group Group×time Safety gloves Time Before intervention After intervention Group Control group Intervention group Group×time
questionnaire were more than scores of observed behaviour checklist. Table 2 shows the results of observed behaviour at workplace. The use of gloves and safety shoes was higher and the use of helmet, mask and safety clothes was less than what they had reported. The proportion of workers who used helmet and dust mask were significantly different before and after the intervention. There was no significant difference in the use of safety shoes and safety clothes (table 3). Regression analysis showed there was no significant relationship between the use of helmet and education level, work history and daily working hours. The OR for using a helmet among intervention group members increased significantly after intervention. We also observed a significant increase in safety mask use after intervention. There was no significant change in the use of safety gloves (table 4).
DISCUSSION This study aimed at assessing the effects of a tailored social marketing intervention based on SMART model. After the intervention, the percentage of workers who used safety mask and helmet in the intervention group was significantly higher than the control group. This result was consequence of providing the workers with PPE and considering key determinants of its usage. In other words, focusing on specific behaviour (using PPE), designing the intervention based on audience analysis and addressing factors that impact on the behaviour made the intervention effective. Tailored intervention significantly increased the use of helmets and safety masks, whereas other behaviours did not change significantly. Despite appropriate knowledge about using PPE and its importance, workers were not willing to use PPE because of perceived barriers to use. They perceived more monetary and nonmonetary costs compared with benefits. So, providing a package based on audience’s wants and needs and giving them the package for free at their workplace, with a persuasive message, made the use of PPE appear more cost beneficial to them. Although many programmes have been planned and implemented to reduce workplace injuries in recent years, workplace injury remains the second leading cause of fatal injuries in Iran. Many interventions were designed based on viewpoints of health and industry experts and were not consumer orientated. Obligating the
OR
p Value
1 3.3
0.007
1 3.9 7.0
0.008 0.024
1 1.1
0.042
1 2.1 2.2
0.035 0.026
1 1.1
0.197
1 −0.03 −0.7
0.969 0.536
employers and contractors to provide PPE and to control working conditions to prevent injury was another important strategy. But education and enforcement are not the only strategies to change social behaviours. For people who are facing a choice with attractive alternatives, or barriers, a third approach is needed. In social marketing approach, planners try to highlight benefits or remove barriers to choice. In this way, target audience motivation to accept an idea or change a behaviour will increase.8 Social marketing tries to produce a product or an intervention considering target audience viewpoints and delivers it to them in appropriate place, with appreciation of costs of the product.2 In Iran, previous studies were designed and implemented to increase the use of PPE and decrease workplace injuries and its consequences,4 but none of them had used social marketing. We hope by showing effectiveness of social marketing approach in workplace, we would encourage more studies to use this approach to prevent risky workplace behaviours and reduce disability and death at workplaces.
What is already known on the subject? Table 3 Number and percent of workers who used personal protective equipment (PPE) in intervention and control groups Intervention station
Control station
Target behaviour
Before
After
p Value
Before
After
p Value
Using Using Using Using
0 0 76 72
43.5 39.1 73.9 69.6
IP Online First, published on April 14, 2015 as 10.1136/injuryprev-2014-041461 Brief report
Persuasion to use personal protective equipment in constructing subway stations: application of social marketing Mahmoud Shamsi,1 Abbas Pariani,2 Mohsen Shams,3 Marzieh Soleymani-nejad4,5 1
Industrial Engineering, Systems Management and Productivity, Isfahan, Iran 2 Center for Control of NonCommunicable Diseases, Deputy of Health, Ministry of Health and Medical Education, Tehran, Iran 3 Social Determinants of Health Research Center, Yasuj University of Medical Sciences, Yasuj, Iran 4 School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran 5 Department of Nursing, Masjed-Soleiman Branch, Islamic Azad University, Masjed-Soleiman, Iran Correspondence to Dr Mohsen Shams, Social Determinants of Health Research Center, Yasuj University of Medical Sciences, Yasuj, Iran; [email protected] Received 15 October 2014 Revised 17 March 2015 Accepted 20 March 2015
To cite: Shamsi M, Pariani A, Shams M, et al. Inj Prev Published Online First: [ please include Day Month Year] doi:10.1136/ injuryprev-2014-041461
ABSTRACT To study the effects of an intervention based on social marketing to persuade workers to use personal protective equipment (PPE) in constructing subway stations in Isfahan, Iran. This was a quasi-experimental study. Two stations were selected as intervention and control groups. Intervention was designed based on results of a formative research. A free package containing a safety helmet with a tailored message affixed to it, mask and gloves and an educational pamphlet was delivered to the intervention group. After 6 weeks, behaviours 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. OR for helmet and mask usage was 7.009 and 2.235, respectively, in the intervention group. Social marketing can be used to persuade workers to use PPE in the workplace.
INTRODUCTION Using personal protective equipment (PPE) as a specialised clothing or equipment worn by an employee for protection is a best practice strategy for reducing occupational injuries.1 In Iran, workplace injuries are the second leading cause of fatal injuries,2 and the reasons for more than 88% of these injuries are not using PPE, not adhering to safety rules and carelessness.2 According to official statistics, mortality rate due to workplace injuries increased 18.8% in the first 6 months of 2010 compared with the same time of 2009,3 and proximate causes of these injuries were lack of guards for instruments and devices, poor quality of tools and devices, carelessness, failure to follow safety rules and crowded equipment in workplaces.3 Failure to use PPE or incorrect usage of PPE is responsible for more than 28% of unsafe behaviours in Iranian workplaces.4 Provision of PPE and its use by construction workers is addressed in Iranian work law.5 Construction industry workers are faced with many occupational injuries and hazards. So, they should use helmet and gloves for preventing head and hand trauma, and dust mask for preventing inhalation of dust and particles. But there are some obstacles to the use of PPE, such as poor quality of equipment, lack of worker education or motivation for its use and lack of a common perception between workers and employers about usefulness of equipments.6 To facilitate individual-based changes or community-based changes, health education alone is insufficient, and marketing concepts must be
applied with a stronger consumer orientation. Identifying the wants and needs of the target audience, as well as the challenges, likes, dislikes and fears related to a health problem and its determinants, is known as consumer analysis by Neiger in the Social Marketing Assessment and Response Tool (SMART) model, as consumer orientation by Lefebvre and Flora and as formative research by Bryant.7 Learning about demographic, psychosocial and behavioural variables through qualitative and quantitative methods is necessary for segmenting the primary general target audience into smaller and more homogenous subgroups and developing the particular interventions needed to modify risky behaviours. In this way, a more effective intervention can be designed and implemented.8 The main question is how we can increase the use of PPE and change workers’ current behaviours in workplaces. Social marketing, defined as “using commercial marketing concepts and techniques for selling an idea or behavior to people”,9 is an approach for changing behaviours that can be used for increasing use of PPE. Social marketing bridges the gap between education and enforcement and is a good solution for those who are aware of the need to change behaviour but have not considered changing it.8 Exchange theory views consumers as acting primarily out of self-interest as they seek ways to optimise value by doing what gives them the greatest benefit for the least cost. This theory reminds social marketers that they must (a) offer benefits that the consumer (not the public health professional) truly values; (b) recognise that consumers often pay intangible costs, such as time and psychic discomfort associated with changing behaviours and (c) acknowledge that everyone involved in the exchange, including intermediaries, must receive valued benefits in return for their efforts.10 It attempts to influence voluntary behaviour by offering or reinforcing incentives and/or consequences in an environment that invites voluntary participation.11 So, it will be useful for the majority of workers who are aware about PPE but do not want to use them while working. In public health, there are some models for applying social marketing in practice. SMART model, developed by Neiger in 1998, is one of these frameworks. In SMART model, intervention is designed based on the findings of a three-step formative research, including consumer analysis, market analysis and channel analysis.12 13 In this study, an intervention based on the SMART model was designed and implemented to persuade workers in two constructing subway stations to use PPE at the workplaces.
Shamsi M, et al. Inj Prev 2015;0:1–4. doi:10.1136/injuryprev-2014-041461
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from http://injuryprevention.bmj.com/ on November 14, 2015 - Published by group.bmj.com
Brief report METHOD This study is a quasi-experimental intervention based on the SMART model. Forty-four employees in two separate subway stations under construction in Isfahan were assigned as intervention and control groups. All constructing subway stations were listed and one of them was selected as intervention station randomly. By considering the similarities in the number and composition of employees in all stations, another one was considered as control station. Intervention and control stations were in north region and centre region of Isfahan, respectively. So, two stations were far from each other and had no relationship. We needed to do formative research to analyse audience, market and channels. So, a qualitative study and a quantitative study were designed. In the qualitative study, focus group discussion (FGD) was used to gather data. A focus group with 11 participants was formed to explore viewpoints of the audience about PPE usage. The participants were selected randomly from both sites. During FGD, we asked the participants to talk about importance of using PPE, factors that influence their use and strategies to increase the use of PPE. The session was held in one of the stations, with the corresponding author as coordinator. Informed consent was obtained from all participants. Two trained note takers attended the session and wrote and taped the discussion. Immediately after the session, the tape and notes were reviewed and main themes were extracted. In the quantitative study, attitudes and self-reported behaviours were measured by a 28-item questionnaire. In this questionnaire, we asked 13 attitude questions with five-level Likert items (from ‘strongly agree’ to ‘strongly disagree’) and seven self-reported behaviour questions with four-level items (from ‘always’ to ‘never’). Workers in both intervention and control stations received the questionnaire and wrote their answers on it. For recording observed behaviours regarding PPE use, a 10-item checklist was used by two trained observers directly. Both tools were developed by the researchers and reviewed by content experts. Data collection was done for 5 days. Based on initial findings, a free package containing a welldesigned light-weighted helmet, a dust mask and safety gloves was delivered to workers in the intervention group. A sticker with an emotionally tailored message reminding them of the importance of caring themselves because of their families was attached to the helmet. This message was developed based on concerns expressed by the workers during FGD. They had told that ‘their families’ were the most important reason for using PPE because injuries would result in problems for their wives and children. In social marketing approach, considering ‘marketing mix’ or 4Ps ( product, price, place and promotion) is fundamental. We considered marketing mix completely. Providing and delivering a free and suitable package containing PPE in workplace and promoting the product by personal communication and applying printed materials were its main components. The intervention was done in the workplace, and stickers with 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 advantages of using PPE and the risks they can reduce. For people who were unschooled, face-to-face counselling 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, we observed the use of PPE in both intervention and control stations using checklists. Paired and independent t tests, χ2 and linear regression were used to 2
analyse the data. The members of the control station received the same package after the evaluation.
RESULTS In FGD, six participants (54.5%) were under 35 years old, literacy level of seven participants (63.6%) was under grade 12 and seven participants (63.6%) had at least 7 years of working history. Most participants believed that PPE ‘protected them against injuries’. Almost all declared it is necessary to use PPE while working. When they were asked about reasons for not using PPE in workplace, participants mentioned some barriers. These included: A helmet interferes with my work and I can’t work easily with it It’s difficult to breath with mask Gloves do nothing for me for serious injury. They just prevent minor wounds which are not important When I work at heights, my helmet falls down.
Some participants also mentioned heaviness, an uncomfortable strap under the chin and reduced proficiency due to helmet use. Some participants said it is difficult to use a helmet in the summer because of excessive warmth. Some believed that PPE is just for certain conditions. These are their quotations: Helmets are just for inside, why do we have to use them outside? I certainly use gloves when carrying beams and pipes, I use masks when there is dust, but why should I use it if there is no dust? I use gloves to protect my hands just in the summer when pipes are hot.
Some participants also mentioned that they would not pay for PPE but would use it if provided by the company, although others stated they would be willing to buy PPE themselves if they were not expensive. Participants had different viewpoints about strategies to increase the use of PPE. Financial support for those who use the equipment, enforcing its usage through worksite supervision (close and remote) and continuing education about the importance of PPE were some of these ideas. Another interesting idea was assigning someone as safety supervisor to notify workers who don’t use PPE. Of all 44 participants, 23 workers (52.2%) were in the intervention group and 21 workers (47.8%) were in the control group. These groups had no significant differences in demographic variables such as age, daily work hours, literacy level and work history. The mean and SD for scores of attitude and self-reported questionnaire and behaviour checklist can be seen in table 1. These findings show that most participants know about the necessity and benefits of using PPE. Participants reported their use of PPE to be good. However, scores of self-reported
Table 1 Attitude, self-reported behaviour and observed behaviour among workers in two stations before the intervention
Attitude Self-reported behaviour Observed behaviour
Score range
Mean (SD)
13–65 7–28 0–10
50.50 (5.69) 15 (4.74) 4 (1.64)
Shamsi M, et al. Inj Prev 2015;0:1–4. doi:10.1136/injuryprev-2014-041461
Downloaded from http://injuryprevention.bmj.com/ on November 14, 2015 - Published by group.bmj.com
Brief report Table 2 Percent of observed behaviours before the intervention Answers
Table 4 workers
OR for using personal protective equipment (PPE) among
Items
Yes (%)
No (%)
Behaviour of using PPE
Used safety shoes while working Used safety clothes while working Used helmet while working Used safety mask while working Used safety gloves while working
68 22 2 6 82
32 78 98 94 18
Helmet Time Before intervention After intervention Group Control group Intervention group Group×time Safety mask Time Before intervention After intervention Group Control group Intervention group Group×time Safety gloves Time Before intervention After intervention Group Control group Intervention group Group×time
questionnaire were more than scores of observed behaviour checklist. Table 2 shows the results of observed behaviour at workplace. The use of gloves and safety shoes was higher and the use of helmet, mask and safety clothes was less than what they had reported. The proportion of workers who used helmet and dust mask were significantly different before and after the intervention. There was no significant difference in the use of safety shoes and safety clothes (table 3). Regression analysis showed there was no significant relationship between the use of helmet and education level, work history and daily working hours. The OR for using a helmet among intervention group members increased significantly after intervention. We also observed a significant increase in safety mask use after intervention. There was no significant change in the use of safety gloves (table 4).
DISCUSSION This study aimed at assessing the effects of a tailored social marketing intervention based on SMART model. After the intervention, the percentage of workers who used safety mask and helmet in the intervention group was significantly higher than the control group. This result was consequence of providing the workers with PPE and considering key determinants of its usage. In other words, focusing on specific behaviour (using PPE), designing the intervention based on audience analysis and addressing factors that impact on the behaviour made the intervention effective. Tailored intervention significantly increased the use of helmets and safety masks, whereas other behaviours did not change significantly. Despite appropriate knowledge about using PPE and its importance, workers were not willing to use PPE because of perceived barriers to use. They perceived more monetary and nonmonetary costs compared with benefits. So, providing a package based on audience’s wants and needs and giving them the package for free at their workplace, with a persuasive message, made the use of PPE appear more cost beneficial to them. Although many programmes have been planned and implemented to reduce workplace injuries in recent years, workplace injury remains the second leading cause of fatal injuries in Iran. Many interventions were designed based on viewpoints of health and industry experts and were not consumer orientated. Obligating the
OR
p Value
1 3.3
0.007
1 3.9 7.0
0.008 0.024
1 1.1
0.042
1 2.1 2.2
0.035 0.026
1 1.1
0.197
1 −0.03 −0.7
0.969 0.536
employers and contractors to provide PPE and to control working conditions to prevent injury was another important strategy. But education and enforcement are not the only strategies to change social behaviours. For people who are facing a choice with attractive alternatives, or barriers, a third approach is needed. In social marketing approach, planners try to highlight benefits or remove barriers to choice. In this way, target audience motivation to accept an idea or change a behaviour will increase.8 Social marketing tries to produce a product or an intervention considering target audience viewpoints and delivers it to them in appropriate place, with appreciation of costs of the product.2 In Iran, previous studies were designed and implemented to increase the use of PPE and decrease workplace injuries and its consequences,4 but none of them had used social marketing. We hope by showing effectiveness of social marketing approach in workplace, we would encourage more studies to use this approach to prevent risky workplace behaviours and reduce disability and death at workplaces.
What is already known on the subject? Table 3 Number and percent of workers who used personal protective equipment (PPE) in intervention and control groups Intervention station
Control station
Target behaviour
Before
After
p Value
Before
After
p Value
Using Using Using Using
0 0 76 72
43.5 39.1 73.9 69.6
