B Free CEED was led by a steering committee made up of community and academic partners as part of a previous program, the Asian American Hepatitis B program/B Free NYC (Trinh-Shevrin et al., 2011). The goal of that program was to raise HBV awareness and increase HBV screening and vaccination behaviors in the Asian American community. The steering committee included Asian American representatives from a community-based organization (CBO) and a community healthcare clinic that both directly serve the Asian American community and was dedicated to developing a strong formative research, dissemination, and evaluation plan from the outset (VanDevanter et al., 2011). Utilizing a CBPR approach, the aim was to design a social marketing campaign informed by research and data that would not only direct the development of a meaningful message but would also identify dissemination channels that are community-centered and relevant.

The formative research phase included: 1) 989 community surveys using venue-based and street intercept sampling of adults (≥18 years) in Chinese and Korean American communities to reach groups underrepresented in population-based assessments; and 2) four focus groups with Chinese American (FG1 n= 9; FG2 n=9; FG3 n=7; FG4 n=8) and three focus groups with Korean (FG1 n=7; FG2 n=10; FG3 n=7) adult community members in their preferred language. Focus groups included individuals 18 to 55 years of age and were conducted in Cantonese, Mandarin, and Korean. Please see Li et al. (2017) for additional information on the community survey methods (Li et al., 2017). Focus group recruitment was led by CBOs using flyers within their community-based centers and focus group guides were developed with guidance from the steering committee and informed by the 4 Ps. Basic descriptive data was derived from the surveys and thematic content analysis was utilized to analyze focus group data, using an iteratively defined codebook. All focus group transcripts were transcribed into English and independently coded by teams of four independent coders representing academic and community partners. Coding discrepancies were presented, discussed, and resolved through consensus in team meetings.

Formative survey findings have been presented elsewhere (Li et al., 2017) and suggested that barriers to screening and vaccination included routinely not seeing a physician for preventive care if they were feeling well, lack of doctor recommendation for screening and vaccination, lack of awareness of HBV vaccination and screening options, being underinsured, and limited time for preventive care (Li et al., 2017). Focus group findings were used to triangulate survey results. Focus group themes confirmed overall survey findings, specifically that both communities highly trust health information from physicians; however, participants reported not seeing a doctor if they felt healthy. Popular health information channels for both communities were traditional ethnic media sources, which participants confirmed had wide community reach. Focus group participants also shared that widespread misinformation about HBV and reluctance to discuss HBV status existed at the community level.

Formative research findings were discussed among the key partners in bi-weekly meetings and monthly steering group meetings. Agreement on campaign strategies, tone, clarity, and persuasiveness was achieved through an iterative process of consensus building. These insights guided the content and format of the campaign message: 1) highlighting awareness of hepatitis B in the community, while challenging misinformation; 2) encouraging individuals to ask their physicians for screening or to seek out screening opportunities; 3) being positive and empowering, rather than fear-inducing and hopeless; and, 4) presenting in a non-health related context to appeal to groups that had been missed by previous HBV campaigns.

Formative findings and major themes were used by a professional marketing agency with expertise in the NYC Asian American market (APARTNERSHIP, 2023) to develop campaign ads and a 30-second video. Next, we engaged in an iterative process of discussion, feedback, and reconciliation of different stakeholder views. Three concepts were developed and pilot-tested in two additional focus groups (FG1 n=8: Chinese American; FG2 n=8: Korean American). Three messages were created in traditional and simplified Chinese, Korean, and English.

The three message concepts included:

Focus group findings revealed the following: 1) the first message concept was not impactful enough and did not convey action; 2) participants liked the second concept but ultimately decided that the concept was too abstract; and 3) participants felt the third concept was the most impactful as it highlighted how pervasive hepatitis B is, how it can strike anyone, and, it conveyed the right tone of urgency. Participants and community partners had no additional edits to the message, but one partner suggested making the video more empowering for the community. The 30-second video follows a man going about his day who is being shadowed by a man in a black body suit, representing HBV. The voice overlay states that HBV is around us and follows us like a shadow, but unless we face it, we could lose what we have. The video was adjusted so that the lead character “strikes back” at hepatitis B, represented by the man in the black body suit. The final message concepts were translated into Korean and Chinese using a transcreation approach (see Figure 2).

The community-based and community-placed dissemination tools and channels utilized for print and video messages were collected from the formative research survey and further discussed and confirmed in the focus groups. Identified channels that were targeted included web-based (e.g., Hey!Korean.com, a Craigslist-like website for the NYC Korean American community, ethnic newspaper websites, CBO partner websites, and the campaign landing page), ethnic media sources (e.g., Korean and Chinese newspapers and television spots), public spaces (e.g., the public library in high-density Asian neighborhoods, cross streets in high foot traffic areas in Asian neighborhoods, and Korean and Chinese American community-serving organizations and businesses, including social services and faith-based organizations, and supermarkets), and Chinatown commuter van lines.

This widespread, web-based dissemination campaign of the video and print ads generated a strong response. The website campaign banner on Hey!Korean.com received 1,585 views over a two-month front-page campaign. The twitter feed @nycHepB had about 21 re-tweets per week and 16 new followers per month, with over 11,067 reached in less than 10 days. The campaign-landing page included information about hepatitis B, testing sites in NYC, links to national HBV resources and campaigns, and print ads of the campaign, including a QR code. Dissemination efforts reinforced each other as campaign ads referred people to the campaign landing page where they could view the video and download print ads. Dissemination events, where print ads were distributed, included Chinese and Korean heritage parades, community policymaker press events, and other community events. Local community partners and coalitions, local Chinese and Korean American medical associations, and additional national partners and coalitions promoted the HBV testing campaign.

A short-term 16-item evaluation using street intercept surveys (N=112), which included items on basic demographics, HBV knowledge and stigma, campaign awareness and message understanding, and campaign impact, was conducted across 2 weeks at different time periods in the targeted Asian neighborhood where the campaign was disseminated to assess campaign awareness and whether they understood the message. Approximately half of the respondents reported seeing the campaign (39.5%) or were unsure if they had seen the campaign (12.5%) after being shown the ad. Ninety-six percent of Korean- and 60% of Chinese Americans were “likely” or “very likely” to get tested or urge others to test for HBV after being shown the print ad during the survey, and over 90% of Chinese- and Korean American respondents reported feeling ‘somewhat’ or ‘very comfortable’ discussing HBV.

The purpose of MARHABA was to examine breast and cervical screening behaviors among Muslim American women in NYC; identify barriers and facilitators to screening; develop small media materials, including brochures and palm cards, to promote screenings; and conduct a RCT to evaluate the impact of a community health worker (CHW) and lay health worker (LHW)-led intervention on screening behaviors. Culturally tailored small media materials were developed using the principles of social marketing, CBPR, and message framing.

Utilizing a CBPR approach, MARHABA was led by a CHW and LHWs, who have less formal training than a CHW, from the NYC Muslim American community and community partners to ensure that the diverse perspectives of these groups were represented. NYC Muslim American community partners provided access to venues for recruitment that included mosques, social service agencies, CBOs, Muslim college student organizations, primary care clinics, and hospitals embedded within the NYC Muslim community. They were also deeply engaged in developing the campaign and the qualitative interview guide through an existing CAB consisting of CBOs and institutional partners.

The formative research phase incorporated the 4 Ps of social marketing into the design of the study instruments: 1) 12 key-informant interviews with NYC Muslim community leaders who worked with the Muslim community to understand contextual factors affecting health-seeking behaviors of Muslim women and recommendations for the development of health programs and intervention; 2) 98 in-depth interviews with Muslim women conducted in their preferred language (including Bengali, Arabic, French, Urdu, and Hausa) to understand barriers and facilitators to breast cancer and cervical cancer screening; 3) 98 surveys which included questions on demographics, access to care, and health information sources among the women taking part in the in-depth interviews; and 4) four focus groups, which were used to evaluate and further develop the materials. Recruitment for the in-depth interviews, surveys, and focus groups included outreach at diverse locations serving Muslim individuals, including health fairs and religious seminars held at mosques and social service agencies, advertisements placed in local ethnic and neighborhood newspapers, and membership lists from mosques and partner agencies.

Findings from formative research have been presented elsewhere (Islam et al., 2017; Patel, 2018) and emphasized the role of structural and socio-cultural barriers to screening, such as insurance, non-gender concordant physicians, language, modesty, immigration status, gender roles and familiarity with the concept of preventive health behavior.

Religion was a facilitator of screening, primarily due to the importance within Islam of individual health. The formative research provided guidance on what messages would motivate Muslim women to obtain cancer screenings. Community members felt that women lacked awareness about how to access and ask for screenings. It was also noted that effective ads should reflect the Muslim community in terms of language concordance and visual content, such as featuring women in a hijab and highlighting the diversity of the Muslim community. A key theme was the centrality of women in the family, in which ads should reflect that: “Taking care of yourself is important for your family.” Finally, respondents felt that the message spokesperson should be either a healthcare provider or a community member/cancer survivor.

From this formative research, four message concepts were developed:

These five print screening messages were previewed by focus groups held with diverse groups of Muslim American women to provide feedback on each message. Four groups were held according to language preference: (FG1 n=11: South Asian; FG 2 n=9: Middle Eastern; FG3 n=10: SE Asian; and FG4 n=7: African American/African immigrant).

The focus groups reviewing the messages found that for the first social marketing message (“A home without a mother is just a house”), the main beneficial aspect was the presentation of the role of the woman in the family, where the mother is central to the functioning of the family. The disadvantages reported were that it appeared chaotic and lacked clarity about the messages (i.e., “unable to understand the message from the photos alone). For concept 2 (“A flower blooms”), some felt the concept was unclear and had to be read to understand. Focus group members felt that concept 3 (“Because we love our queen bee”) was advantageous in the way it portrayed the woman’s role in the family, her centrality to the family, and her responsibility to the family. Some members felt the message was unclear and hard to see how it related to cancer. Focus group members liked campaign 4A (“A journey to hope – Famous Muslim Woman”), as it worked with the benefits of using a celebrity spokesperson and the attention that brings to the ad. They also liked message 4B (“A journey to hope – Cancer Survivor”) because it had a clear link to cancer and that the person who had cancer was now okay: “She is creating consciousness.” Overall, the focus group participants felt that the messages needed a clear and instant link to cancer screening. Campaign 4B was chosen from this work (see Figure 3). This message was then translated into Bengali, Arabic, and Urdu in consultation with community partners using a transcreation approach.

Key-informant interviews helped guide the dissemination efforts of the social marketing campaign, which highlighted mosques and religious leaders, as well as ethnic media and CBOs (Islam et al., 2017). Small media materials designed during the formative work were also utilized in the MARHABA RCT intervention study. To be eligible for the study, women had to self-identify as Muslim and be due for breast and/or cervical cancer screening. All women enrolled in the study received an educational seminar led by a CHW where the women were provided with small media education materials. After completion of the seminar, participants were randomized into the control arm (no further contact) or the intervention arm (additional navigation to provide support for screening). Details of the RCT are presented elsewhere (Wyatt et al., 2023).

An analysis of self-reported breast and cervical cancer screening during the MARHABA RCT follow-up survey suggested that the small media materials developed were effective in improving breast and cervical cancer screening among Muslim women living in NYC. Bivariate analyses and chi-square testing found that mammogram screening increased from 16.0% to 49.0% in the intervention arm (p<0.001), and from 14.7% to 44.6% in the control arm (p<0.001); similarly, cervical cancer screening increased from 17.0% to 43.0% in the intervention arm (p<0.001), and from 18.7% to 40.4% in the control arm (p<0.001) (Wyatt et al., 2023). The adjusted models found no significant group differences between arms, suggesting that the education seminar and the small media materials may have helped to successfully improve the uptake of breast and cervical cancer screening among this group of Muslim American women.