The Positive Choices trial: study protocol for a Phase-III RCT trial of a whole-school social marketing intervention to promote sexual health and reduce health inequalities

Background Positive Choices is a whole-school social marketing intervention to promote sexual health among secondary school students. Intervention comprises school health promotion council involving staff and students coordinating delivery; student survey to inform local tailoring; teacher-delivered classroom curriculum; student-run campaigns; parent information; and review of sexual/reproductive health services to inform improvements. This trial builds on an optimisation/pilot RCT study which met progression criteria, plus findings from another pilot RCT of the Project Respect school-based intervention to prevent dating and relationship violence which concluded such work should be integrated within Positive Choices. Young people carry a disproportionate burden of adverse sexual health; most do not report competence at first sex. Relationships and sex education in schools can contribute to promoting sexual health but effects are small, inconsistent and not sustained. Such work needs to be supplemented by ‘whole-school’ (e.g. student campaigns, sexual health services) and ‘social marketing’ (harnessing commercial marketing to social ends) approaches for which there is good review-level evidence but not from the UK. Methods We will conduct a cluster RCT across 50 schools (minimum 6440, maximum 8500 students) allocated 1:1 to intervention/control assessing outcomes at 33 months. Our primary outcome is non-competent first sex. Secondary outcomes are non-competent last sex, age at sexual debut, non-use of contraception at first and last sex among those reporting heterosexual intercourse, number of sexual partners, dating and relationship violence, sexually transmitted infections, and pregnancy and unintended pregnancy for girls and initiation of pregnancy for boys. We will recruit 50 school and undertake baseline surveys by March 2022; implement the intervention over the 2022–2024 school years and conduct the economic and process evaluations by July 2024; undertake follow-up surveys by December 2024; complete analyses, all patient and policy involvement and draft the study report by March 2025; and engage in knowledge exchange from December 2024. Discussion This trial is one of a growing number focused on whole-school approaches to public health in schools. The key scientific output will be evidence about the effectiveness, costs and potential scalability and transferability of Positive Choices. Trial registration ISRCTN No: ISRCTN16723909. Trial registration summary: Date:. Funded by: National Institute for Health Research Public Health Research Programme (NIHR131487). Sponsor: LSHTM. Public/scientific contact: Chris Bonell. Public title: Positive Choices trial. Scientific title: Phase-III RCT of Positive Choices: a whole-school social marketing intervention to promote sexual health and reduce health inequalities. Countries of recruitment: UK. Intervention: Positive Choices. Inclusion criteria: Students in year 8 (age 12–13 years) at baseline deemed competent by schools to participate in secondary schools excluding pupil referral units, schools for those with special educational needs and disabilities, and schools with ‘inadequate’ Ofsted inspections. Study type: interventional study with superiority phase III cluster RCT design. Enrollment: 1/9/21-31/3/22. Sample size: 50 schools and 6440–8500 students. Recruitment status: pending. Primary outcome: binary measure of non-competent first sex. Secondary outcomes: non-competent last sex; age at sexual debut; non-use of contraception at first and last sex; number of sexual partners; dating and relationship violence (DRV) victimisation; sexually transmitted infections; pregnancy and unintended pregnancy for girls and initiation of pregnancy for boys using adapted versions of the RIPPLE measures. Ethics review: LSHTM research ethics committee (reference 26411). Completion data: 1/3/25. Sharing statement: Data will be made available after the main trial analyses have been completed on reasonable request from researchers with ethics approval and a clear protocol. Amendments to the protocol will be communicated to the investigators, sponsor, funder, research ethics committee, trial registration and the journal publishing the protocol. Amendments affecting participants’ experience of the intervention or important amendments affecting the overall design and conduct of the trial will be communicated to participants.

Can an Index Approach Improve Social Marketing Competitor Analysis?

Background: Competitive forces influence social marketing efforts. Indeed, social marketers often find themselves “shadow boxing” various forms of competition throughout their interventions. Despite the seminal role of competition as a threat to social marketing intervention efficacy, few empirical studies have undertaken competitive analysis or compared the usefulness of competitive typologies. Thus, this paper proposes an index approach to categorize competitive typologies relevant to a specific social marketing intervention in terms of their ease of use, intuitiveness and generalisability to the broader social cause domain. The proposed index approach is illustrated with empirical data, undertaking a competitive analysis of forces obstructing efforts to address educational inequality in Australia, then comparing the ease of use, intuitiveness and generalisability of 15 competitive typologies noted in the social marketing literature to produce a competitor analysis index. Research Question: Which competitive typologies most effectively frame forces that inhibit educational equality social marketing efforts in Australia? Methods: Via interviews and focus groups, qualitative data were collected from 46 students from low socioeconomic status (LSES) backgrounds at six universities and sought to understand the influence of their home residence’s geographical remoteness on their university participation. The analysis revealed eight participant-identified differential competitors experienced by students from regional, rural and remote settings (LSES-R, n = 25, 54.4%) that were not experienced by those from metropolitan areas (LSES-M, n = 21, 45.6%). Fifteen competitive typologies were identified in the social marketing literature, and their capacity to frame these eight differential forces in terms of their ease of use, intuitiveness and generalisability was critiqued. Findings: Unlike their metropolitan counterparts, LSES-R participants experienced situational (n = 3), dispositional (n = 3) and goal pursuit (n = 2) competitive forces. The most effective competition typologies comprised two classification options that were distinctly different and could classify both the unfriendly and friendly competition that exists in social marketing. Five competitor typologies were identified as easy to use, intuitive and generalizable to the broader educational inequality domain. Together, these five competitor typologies form a competitor analysis index for educational inequality researchers and practitioners to enhance their intervention efficacy. Recommendations: Despite widespread agreement as to the importance of competitor analysis in social marketing, the efficacy of various typologies has received little attention. Social marketers are encouraged to critique competitor typologies before selecting those which enable effective decision-making. Furthermore, it is recommended that social marketers use a competitor analysis index comprised of multiple typologies to better capture the nebulous nature of the many different types of competitors that exist in a specific social marketing context. Limitations: The educational inequalities cause and qualitative method may constrain generalisability, but they exemplify the importance of competition typology choice and model how competitor analysis indexes can be developed.

Dance Is for All: A Social Marketing Intervention with Children and Adolescents to Reduce Prejudice towards Boys Who Dance

Dance is proven to offer a myriad of physical, psychological, and social benefits. However, because dance has been frequently perceived as a feminine practice, there is a prevailing prejudice towards boys who dance, making it hard for them to engage in this physical activity. Social marketing has been presented as a promising framework to deal with different social problems, including prejudice, although its effectiveness is still difficult to establish. Drawing on the Theory of Planned Behavior (TPB), a quasi-experimental study involving a sample of 436 children and adolescents, composed of 51.38% boys and 48.62% girls was implemented to measure the effectiveness of a Social Marketing Intervention (SMI) in reducing prejudice towards dance and boys who dance, in particular, and in increasing their intentions to practice this physical activity. The study furthermore aimed to compare the influence of the SMI on participants of two different stages of child development to ascertain when it is most effective to intervene. The questionnaire was used to collect information and included items derived from relevant literature. To assess differences between children and adolescents before and after the SMI, the analysis relied on independent t-tests and paired t-tests. Results suggest positive effects of the SMI on some dimensions of the TPB.

Effects of Social Marketing Intervention on Physical Activity promotion Among the Elderly

Background: Social marketing emphasizes the use of commercial marketing concepts and their application for social purposes and also the change of voluntary behavior in a nonprofit manner. This study mainly aimed to examine the effectiveness of social marketing in changing the physical activity of the elderly. Besides, this study sought to determine the extent to which the Andreason social marketing criteria have been targeted in social marketing interventions. Methods: This was a narrative review study that investigated social marketing interventions to promote elderly physical activity, during 2000-2019. The scientific databases (Elmnet, SID, Irandoc, Civilica, Medline, ScienceDirect, Google Scholar, Web of Science, ProQuest, and Emerald) were searched between February and March 2019. The searched keywords included physical activity, social marketing, the elderly, social marketing mix, improving physical activity level, social marketing intervention, social marketing campaigns, and the Andreasen criteria. Finally, nine articles entered the study. Then, the mixed marketing components were extracted from the interventions, and six benchmarks of the Andrasen social marketing interventions were analyzed. Results: Most articles employed four components of the marketing mix. No intervention had applied the six measures of the Andrasen social marketing criteria. Also, five studies reported positive behavioral changes. However, other studies have reported no change in negative behavior. According to the evidence gathered in our study, social marketing offers an effective behavioral change approach to increase physical activity in the elderly. Conclusion: The present findings provide the basis for comprehensive and effective social marketing interventions.

Evaluating Stochastic Seeding Strategies in Networks

When trying to maximize the adoption of a behavior in a population connected by a social network, it is common to strategize about where in the network to seed the behavior, often with an element of randomness. Selecting seeds uniformly at random is a basic but compelling strategy in that it distributes seeds broadly throughout the network. A more sophisticated stochastic strategy, one-hop targeting, is to select random network neighbors of random individuals; this exploits a version of the friendship paradox, whereby the friend of a random individual is expected to have more friends than a random individual, with the hope that seeding a behavior at more connected individuals leads to more adoption. Many seeding strategies have been proposed, but empirical evaluations have demanded large field experiments designed specifically for this purpose and have yielded relatively imprecise comparisons of strategies. Here we show how stochastic seeding strategies can be evaluated more efficiently in such experiments, how they can be evaluated “off-policy” using existing data arising from experiments designed for other purposes, and how to design more efficient experiments. In particular, we consider contrasts between stochastic seeding strategies and analyze nonparametric estimators adapted from policy evaluation and importance sampling. We use simulations on real networks to show that the proposed estimators and designs can substantially increase precision while yielding valid inference. We then apply our proposed estimators to two field experiments, one that assigned households to an intensive marketing intervention and one that assigned students to an antibullying intervention. This paper was accepted by Gui Liberali, Special Issue on Data-Driven Prescriptive Analytics.

Impact of a Social Marketing Intervention on General Practitioners’ Antibiotic Prescribing Practices for Acute Respiratory Tract Complaints in Malta

Introduction: Antibiotics are commonly prescribed in primary care for acute respiratory tract complaints (aRTCs), often inappropriately. Social marketing interventions could improve prescribing in such settings. We evaluate the impact of a social marketing intervention on general practitioners’ (GPs’) antibiotic prescribing for aRTCs in Malta. Methods: Changes in GPs’ antibiotic prescribing were monitored over two surveillance periods between 2015 and 2018. Primary outcome: change in antibiotic prescription for aRTCs. Secondary outcomes: change in antibiotic prescription: (i) for immediate use, (ii) for delayed antibiotic prescription, (iii) by diagnosis, and (iv) by antibiotic class. Data were analysed using clustered analysis and interrupted time series analysis (ITSA). Results: Of 33 participating GPs, 18 successfully completed the study. Although clustered analyses showed a significant 3% decrease in overall antibiotic prescription (p = 0.024), ITSA showed no significant change overall (p = 0.264). Antibiotic prescription decreased significantly for the common cold (p < 0.001), otitis media (p = 0.044), and sinusitis (p = 0.004), but increased for pharyngitis (p = 0.015). Conclusions: The intervention resulted in modest improvements in GPs’ antibiotic prescribing. A more top-down approach will likely be required for future initiatives to be successful in this setting, focusing on diagnostic and prescribing support like rapid diagnostic testing, prescribing guidelines, and standardised delayed antibiotic prescriptions.

A Social Marketing Intervention to Improve Treatment Adherence in Patients with Type 1 Diabetes

This research explores if a social marketing intervention model based on social representations theory and the health belief model can generate changes regarding treatment adherence and improve patient self-efficacy. As a pilot, a test–retest field quasi-experiment was designed to evaluate the intervention model with type 1 diabetes (T1DM) patients of families with 8- to 17-year-old children. The intervention model was designed to clarify misconceptions, increase awareness of the benefits of following doctors’ treatments and improve patients’ self-efficacy. In-depth interviews were carried out to gain a richer understanding of the intervention’s effect. The pilot intervention generated a favourable change in shared misconceptions, individual health beliefs, glycaemic control and declared treatment adherence. This paper contributes to the social marketing literature and public health by providing early support for the theoretical assumptions regarding the role of shared misconceptions in physiological and behavioural outcomes for patients with T1DM. Contrary to previous studies, instead of only focusing on individual beliefs, this study incorporates shared beliefs between patients and caregivers, generating more comprehensive behavioural change.