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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
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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 April 15, 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
<0.001
<0.001
0.329
0.329
4
12
88
64
27.3
18.2
91
68.2
0.021
0.329
0.329
0.747
helmet
safety mask
safety gloves
safety shoes
Shamsi M, et al. Inj Prev 2015;0:1–4. doi:10.1136/injuryprev-2014-041461
▸ Prevention of workplace injuries by using personal protective
equipments (PPEs) is a best practice.
▸ Some behaviour change strategies like education and
enforcement have been used to increase the use of PPE in
workplaces in Iran. However, many workers have not been
willing to use PPE while working.
▸ Although social marketing is known as an effective strategy
to change behaviours, it has not been employed to prevent
injuries in the workplace.
3
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Brief report
2
What this study adds?
3
▸ Strategies based on consumer orientation, like social
marketing, can be successful in addressing health issues.
▸ Making the beneﬁts prominent and/or reducing the tangible
and intangible costs of engaging in a behaviour can result in
the uptake of that behaviour, such as using PPE in the
workplace.
4
5
6
7
Contributors MaS: developing the proposal draft, administrating the intersectoral
coordination, managing the FGDs and survey, analysing the data. AP: modiﬁcation
of the proposal drafts, note taking in FGDs, gathering data through survey. MoS:
developing the research subject, ﬁnalising the proposal, supervising the activities,
analysing the gathered data, developing the intervention, ﬁnalising the manuscript.
MS-n: helping data analysis, writing manuscript drafts and editing them according to
team’s comments.
9
10
Competing interests None.
11
8
Provenance and peer review Not commissioned; externally peer reviewed.
12
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Shamsi M, et al. Inj Prev 2015;0:1–4. doi:10.1136/injuryprev-2014-041461
Downloaded from http://injuryprevention.bmj.com/ on April 15, 2015 - Published by group.bmj.com
Persuasion to use personal protective
equipment in constructing subway stations:
application of social marketing
Mahmoud Shamsi, Abbas Pariani, Mohsen Shams and Marzieh
Soleymani-nejad
Inj Prev published online April 14, 2015
Updated information and services can be found at:
http://injuryprevention.bmj.com/content/early/2015/04/14/injuryprev2014-041461
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