Selling Us To Ourselves | Community HIV/AIDS Mobilization Project

Selling Us To Ourselves:

Is Social Marketing Effective HIV Prevention?

Tuesday, September 26, 2006
6:30 – 8:30PM

LGBT Center, New York City

From bus shelter ads to give-aways in our communities, social marketing is becoming a larger part of community HIV prevention efforts. But is marketing an effective public health tool, or is it just another facet of consumer culture that sells our lives back to ourselves? Is it a vital means for reaching those who are not in the loop of community organizations, a way of refreshing the messages on AIDS after decades of efforts? Do some social marketing efforts have unintended consequences of stigmatizing community members?

Co-sponsors:
Black Gay Men's Leadership Council, Philadelphia
Community HIV/AIDS Mobilization Project (CHAMP)- www.champnetwork.org
Gay Men's Health Crisis (GMHC)- www.gmhc.org
LGBT Community Center- www.gaycenter.org
New York State Black Gay Network- www.nysbgn.org

COMMUNITY FORUM MATERIALS: SPEAKER PRESENTATIONS

Elizabeth Losh, University of California, Irvine
PowerPoint Presentation
Knowing Is Beautiful movie
Welcome to Norway movie

Anthony Morgan, New York State Black Gay Network
PowerPoint Presentation

Les Pappas, Better World Advertising, San Francisco
PDF Presentation

Kevin Trimell Jones, Black Gay Men’s Leadership Council, Philadelphia
PowerPoint Presentation

Moderated by: Julie Davids, CHAMP

Summary of Discussion:

Welcome, Julie Davids, CHAMP

Below is a summary of Julie’s remarks:

I was in the Nashville airport a few days ago. There was a sign that said: “Veterinarians: Doctors protecting the health of animals and people.” Wow, after that I felt so good about veterinarians and my relationship to them. But in reality social marketing is not so simple. Part of what we're going to talk about today is this intersection between society and marketing. It is a very new and different form of HIV prevention.

A big question in social marketing is audience: a target audience. If it's on the side of a bus, then who is the audience? Where does the responsibility lie in what happens when a message reaches an unintended audience? We haven't had opportunities to talk about social marketing as a medium—except in the context of controversy.

Social marketing uses media as a marketing tool—so that means we need to think about media literacy. What does it mean to consume social marketing? Is it inherently different from an individual intervention?

We also will talk about stigma—can social marketing combat stigma? How has social marketing used stigma as a tool (i.e. anti-smoking campaigns)? This sometimes occurs in conjunction with structural interventions such as raising the price of cigarettes. What's the role of dignity—how can we enhance the dignity of people depicted or audiences in social marketing? Lastly, evaluation—what can this look like, how can it be built in, how can people involved think through this and who should be doing the evaluations? What are the unintended consequences of social marketing and how should they be evaluated?

Les Pappas, Better World Advertising
Click here to see Les Pappas’ presentation

Below is a summary of Les’s remarks:

My background is with the San Francisco AIDS Foundation (1984-1994), and then 10 years ago I started Better World Advertising. We work exclusively with non-profit groups, community organizations, health departments, and universities, in about eight states.

I will talk generally about why social marketing is important (namely, because it works). Social marketing is hard to do well, but it’s really not that mysterious. The grandfather of social marketing is Smokey the Bear—he’s well into his sixties now. Day in and day out he gets the message out in a very basic way. He communicates important messages about our environment and our behavior.

My definition of social marketing is: the blending of traditional public health methods with contemporary marketing and advertising techniques to communicate with defined groups of people on health and social issues with the goal of changing individual behaviors, usually through modification of group norms. This includes integrating the values, needs, and concerns of the target audience and the community into program planning and implementation.

Key concepts for social marketing are inclusiveness, research, creativity, testing, and evaluation. Populations may often be marginalized and have specific needs. Therefore, we need to look at: 1) the advertising environment (or, getting people's attention); 2) literacy (reading ability and comprehension); 3) altered consciousness (for example, if your target population is people who are strung out on meth); 4) how people learn (visual/written/verbal); 5) interactivity (how to actively engage people); and 6) is it (media) worthy? Being media-worthy means getting expanded reach.

Does advertising/marketing work, and is social marketing effective? Yes, and yes. Corporations spend billions of dollars on advertising. They wouldn't be doing this if it didn't work. Total advertising spending in the US in 2005 was $271 billion. Advertising is highly effective at reaching people. Specifically in terms of social marketing, statistics on cigarette smoking reduction are a clear result of aggressive, well-funded anti-smoking campaigns.

It is a really a question of resources and quality. Bad social marketing is generally bland, safe, and pretty ineffective. This is because it comes from the government and the government is particularly cautious. We also get ineffective social marketing for other reasons, including lack of resources, government regulation and censorship, amateur versus professional differences, and a lack of appreciation of what it takes to reach people or to motivate change. It takes work, resources, and consistent investment.

Change can come in different ways. It can come from attracting people (getting them on the bandwagon), but it also comes through disturbing them or causing them discomfort (so they're challenged in some way to move to make a change). We like it when it makes us “feel good” but we don't like it when it confronts our reality, shocks us, airs our dirty laundry, or makes us think too much. But why do we think that we have to like or approve or agree with social marketing? Ultimately, what is the role of controversy? We need to leverage the scarce resources we have, and we need to get people's attention. The first hurdle is getting people's attention; then, you can gauge people and deal with other hurdles.

Examples from our campaigns:

1. “Bleach man”: superhero for injecting drug users, shows respect, went over really well

2. GMHC: “I know my son messes around with men. We never talk about it, but I want to support him.”

3. Healthy penis campaign: We have great data on this. We compared people who were exposed to the campaign and people who were not. The people who were exposed were more informed about symptoms, modes of transmission, more likely to have gotten a recent syphilis test (goal of campaign). There was 80% saturation, and nearly twice as many people went and got a syphilis test after seeing the campaign (46% to 26%). Syphilis testing went way up.

4. HIVstopswithme.org: Prevention with positives. Evaluation data (self-reported) shows that people are more likely to use condoms, more likely to feel responsibility for HIV prevention, more likely to disclose my HIV status before sex, and more likely to believe a responsibility to keep partners negative.

Now what about campaigns that people don't like so much? What about campaigns that make people feel bad? For example, we launched the HIV (not fabulous) campaign. We had a gentleman with facial wasting, we had a gentleman in a diaper because of chronic diarrhea, and we had a gentleman with a bloated belly. People thought it was stigmatizing people with HIV, but what I can speak for is the e-mails that we received about the ads. We had a lot of people complaining, but we also had a lot of people who had no idea that HIV was so bad. Young gay men in Los Angeles woke up with this campaign—it gave them a reality check and changed their behavior in terms of protecting themselves.

The last comment I want to make is about a new campaign recently launched in Los Angeles: “HIV is a gay disease- Own it. End it.” 75% of people with HIV are gay and bisexual men in LA. Distancing ourselves from that, saying it's not our disease anymore does not help us deal with prevention.

Anthony Morgan, New York State Black Gay Network

Click here to see Anthony Morgan’s PowerPoint presentation

www.wearepartofyou.org

Below is a summary of Anthony’s remarks:

I’m from the NYSBGN, which is a coalition of 15 diverse organizations who seek to end the epidemic. We are located within the five major urban cities of New York State, and our goal is to assist communities to respond to the needs of black gay men in a more responsive and appropriate way.

2005 was the “summer of our discontent.” The CDC released a study that showed that 46% of black gay men were HIV positive. At the same time, we also saw murder rates and bashings at an unforgivable level—in Brooklyn, Queens, and the Bronx. We pulled together our organizations and created different opportunities for community members to respond to this. An outgrowth of this was the Campaign for Black Gay Men's Lives—we have been working with CHAMP on how to train black gay men in speaker's bureaus techniques and how to talk about these issues with people in their community and with elected officials.

In terms of social marketing, our goals were to decrease stigma, decrease homophobia, and challenge the silence among black and black gay communities. The question was: “Who gives a shit about our lives besides us?” We wanted to have visibility as an organization working to stem the tide of the epidemic, and as black, gay men we wanted to make sure that we didn't just die off the face of the earth. We wanted to have an enormous reach at the community level, primarily targeting heterosexual African-American folks. We wanted to put these issues on the table instead of behind closed doors.

How come everyone is just talking about testing, not about co-factors? Let's talk about stigma and homophobia, and hopefully the work of people doing testing will also be improved.

We organized a 32 member organization, particularly downstate, and partnered with Better World Advertising. We geared the message to the mainstream black community. We want a unified approach with heterosexuals to end the epidemic together. We began concept testing in two groups—black straight and black gay/bisexual. The actual campaign launched in August in Bedford Stuyvesant (Brooklyn), East New York (Brooklyn), Central and East Harlem, and Jamaica (Queens), where there is the most violence against black gay men as well as the highest HIV prevalence rates. We specifically decided not to target Chelsea; our target was heterosexual black communities. Let's have this be IN and FOR black communities. So many of us live in these black neighborhoods and then “fag out in Chelsea,” ignore our sexual identities in our black neighborhoods.

We launched a campaign website: www. wearepartofyou.org. The message is: We are 46% HIV-positive, and you are 46% too. The ads say things like: “I am gay and this is where I pray,” and “I am gay and this is where I play.” We wanted to model behavior, showing that we are part of the community and have always been. We are uncles, fathers, nieces, nephews and sons.

The reach so far has shown over 8,000 visits to the website from over the world in five weeks. Africa is also really clicking on, and people are staying there five or ten minutes. The MTA (NYC Transit) estimates that 393 million people see the campaign over a span of four weeks in the transit system. We have also gotten a lot of coverage in the gay press, and we did a press conference at the location of the billboards. Finally, we created a feedback survey and we are doing street intercepts, especially tracking heterosexual media that we get.

But now what? We soon hope to address HIV/AIDS stigma in black communities and expand the current campaign to upstate/western NY and nationally.

Elizabeth Losh, University of California, Irvine

Click here to see Liz Losh’s PowerPoint presentation
Knowing Is Beautiful movie
Welcome to Norway movie

Below is a summary of Liz’s remarks:

My presentation is entitled: “Social marketing, public rhetoric, and the branding of a disease.” It’s basically a history of 20 years of social marketing in 10 minutes.

In 1986, the first surgeon general's report came out on HIV; it depicted condoms, but not faces of people. There were also a lot of medical illustrations utilized in the 1980’s. The New York State Department of Health put on a campaign in 1987 showing images of shaking hands, toilet, doorknob, and plates. This indicated a reliance on symbols, instead of a more humanizing approach to disease. In 1988, the Koop brochure was sent to 197 million households. This brochure was illustrated with faces and headshots, but no condoms were used. In 1992, another surgeon general’s report came out, this time using group photos rather than individual humanizing faces; there were also a lot of bar charts and the depiction of condoms re-appeared.

Now let’s think about the present and the way that digital media impacts social marketing. The Internet allows for an increased amount of role-playing activities as well as anonymity. Interactive platforms can model decision-making, and the government is beginning initiatives with new technology. In 2002, for example, Dartmouth attempted to release a social marketing campaign called “HIV Prevention Counseling: A Client Centered Approach,” but it was never released because of political pressure! (There was a transvestite character, which perhaps was one reason). Between 2004 and 2007, there was the “Virtual Sex Project,” which was later re-named the “Virtual Sex Real Risk Reduction Project.” This project targeted black gay men, and the name was probably changed due to government funding. Another successful campaign in 2006 was the “My Sexy City” website, sponsored by GMHC and AIDS Project Los Angeles. Also in 2006 was the “IN SPOT LA” campaign (AHF and Internet Sexuality Information Service), which allowed users to send postcards to sex partners anonymously encouraging them to get tested. Finally, a new technology being utilized is video games: the University of Connecticut sent out proposal for innovative game designers to create an HIV prevention game, building on human sexuality work done by the Savannah Institute.

So why social marketing? It represents decisions made by people of power and authority. Those people do not profit financially from the success of the campaign. It is also involved in risk-communication, a genre of getting people aware (and, like the duck and cover campaigns in 1950's, are not necessarily realistic or effective). Social marketers aim at unique needs and experiences of their target audience.

Customer desire is at the center of its rhetorical appeal. Yet American campaigns are stymied by Puritanism about the body and sexuality. This is sometimes negated by a few successful campaigns, such as the 1990 “Safe Sex is Hot Sex” campaign. Another campaign, “Knowing is Beautiful,” recently created a negative response through its portrayals glamorizing HIV testing through Gap-like models (see video clip here). Crispin Porter defended it by arguing, “What if we made it seem a cool thing? Something people aspire to?”

These are the two general approaches: subvert dominant social attitudes or reinforce them. An example of the first approach is seen in Amnesty International’s campaign on violence against women. It criticizes the consumption and fetishism of the female body as young and sexy. In this campaign, they use the imagery of a travel campaign for Norway with the subversive end of noting that this is a society that allows violence against women (see video clip here).

The other approach is to shock the viewer, for example, with the image of the ugly mouth of smoker. Are there ways that these campaigns can shock as well as remain humanizing? In addition, is it wrong to use attractiveness if people respond to it (like the “Small Steps” campaign by CDC)? How do images of bloated bellies, even shot with dignity, change or reinforce our perceptions of beauty?

Another example of a dangerous social marketing situation is the “Brand X v. Brand Y” scheme. One example of this is the “Blood Saves” Campaign. It highlights Julie and Charlie, one fighting against labor injustice and one against environmental pollution, and they each end up harming the each other’s cause. The message is that social action has unintended consequences, so, according to the ad, you should just give blood because it’s so easy and has none of these unintended side effects. This campaign was pulled.

Finally, a few last things to think about. How about the Better World Advertising campaign: “I didn't survive HIV in order to die from smoking”? How do we feel about the branding of “We all have AIDS” as a kind of “Got Milk?” campaign, using celebrity status? What about utilizing sentiment and Americana, even though some populations are excluded? How about scare tactics, such as coffins? In regards to all these campaigns, we must continually be aware of the possibility of creating cognitive dissonance among grassroots level.

Kevin Trimell Jones, Black Gay Men’s Leadership Council

Click here to see Kevin Trimell Jones’ PowerPoint Presentation

Philadelphia pulls ads featuring young black men in crosshairs - The Philadelphia Inquirer

Below is a summary of Kevin’s remarks:

My presentation today is addressing the “Have You Been Hit” social marketing campaign in Philadelphia. I am from the Black Gay Men’s Leadership Council, which is working on the need to address different areas of black gay men's lives outside of just HIV, including working on health and wellness, leadership, and employment.

The social marketing campaign featured black men in the target of a gun with the words, “Have you been hit? Don't Guess. Take the Test.” This campaign was funded by city of Philadelphia who hired Zigzag Net to target the local MSM population with the goal of promoting HIV testing.

Our critiques of the campaign are first with the use of violence:
1. High rates of gun violence/homicides in Philadelphia
2. Violence and HIV infection are both public health issues
3. Violence traditionally used in conjunction with marginalized groups
4. Campaign was out of step with efforts to end youth homicides

Fear-based campaigns do not sustain behavior over time. This is an example of what we call a “band-aid” approach. It also doesn’t address the role of people living with HIV. For example, are HIV-positive people sexually targeting negative individuals? Are they holding a loaded gun, aiming to infect HIV-negative partners? This campaign creates a fatalistic message and doesn’t encourage responsibility for both partners in prevention.

The campaign also failed to deal with other co-factors. Even with black gay men or other communities, there is this notion of low self-worth; these campaigns might indirectly give the message to these individuals that HIV is unavoidable. Also, how do campaigns like this affect our notions of love and trust in relationships?

Ultimately, this campaign is about being sex-negative versus sex-positive (gay sex being negative). It negates notion of self-responsibility, particularly for HIV negative men, while HIV positive people carry the entire responsibility for transmission.

Other critiques include: Was this best use of money? $236,000 was spent on a campaign that ran for three months. Did the campaign actually reach a broader audience, and was there even an evaluation plan (no). What about the need for a hotline?

So what can we learn from this campaign? We need to move forward with city and community involvement in social marketing. Campaigns must be developed in partnership with communities versus in isolation. Communities should be given funding to do local research. I’d also like to mention the six fundamental principles of the “Gay men's health movement”—which include replacing an HIV-centric paradigm of health advocacy for gay men with holistic models that integrate HIV. We also need to confront structural issues like racism, sexism, heterosexism, and economic inequality. Finally, we should launch campaigns that are not overtly or covertly sanitizing, sanctimonious, or moralizing.

Summary of Questions and Discussion:

Question: What about MSM and substance abuse? Why did that not come up in any of the presentations or in the social marketing campaigns? Is there a double stigma?

Anthony: For the first year of our campaign we made a decision to target black heterosexuals addressing specifically the issue of homophobia. We didn't want many messages, just one. When we talk about stigma in our future campaigns, we want to talk about substance use.

Question: Do you have any broad advice for organizations working on small budgets to undertake a scientific and practical evaluation plan?

Les: It is unrealistic to do a full evaluation on small budget. For a moderate size campaign, you can survey people using websites, etc. These are convenience samples—not randomized. It would be quantitative, but not randomized. I still think it can be valuable. You can also do smaller qualitative stuff too.

Kevin: Think outside the box. Check in with local universities and colleges. See if they have graduate programs where a student needs a research project. Students could do it for the sake of credit or as a part of a service-learning program.

Question: Why did the Philadelphia campaign end after 3 months?

Kevin: The halting of the campaign was partially due to our efforts. We continued to try to meet with Health Department. We wrote a press release, and Julie Davids helped us get it in the newspaper. Then the campaign ended. \

Question: Have social marketers ever thought about trying to engage mainstream spaces such as pornography where people think about sex (i.e. portraying safer sex messages and behaviors in porn)? Is this still considered social marketing?

Liz: Check out the work of Linda Williams at UC Berkeley who looks at pornography from a feminist perspective. I don’t think this would exactly be social marketing, since there is not a focus on product and price -- not the “scientificness” of the advertising industry

Question: Les used the phrase: “Amateur versus professional” social marketing. What do you mean? How does this relate to community involvement and peer education, for example? Professionalization doesn’t necessarily mean effective – i.e. the Aldo “See no evil, hear no evil” ads that don’t make any sense.

Les: If I have a cavity, I want to go to the dentist. We try to bring people into the process, but there has to be an acknowledgment they don't necessarily have the skills and experience.

Liz: The FDA does social marketing that is truly terrible, confusing, and unclear, so professional doesn’t mean good necessarily. But there can also be excessive branding. How is HIV branded? “We all have AIDS” -- is not very clear. What is the behavior change? It's all branding and nothing concrete.

Julie: Some alleged social marketing is just commercial advertising, which is what I would say about the Aldo campaign. Or there may be an additional step someone has to take to get the explicit information, such as the billboards that are a part of the Viacom-Kaiser “Know HIV/AIDS” campaign – you have to go to a website or call a phone number for information.

I think sometimes what happens is people are so grateful to see HIV get mentioned in public/mainstream spaces at all that we actually have very low standards. We think, “Wow! Someone cares!” It implies that things are being done when they're not. We have every right to critique media campaigns that are solely about awareness.

Question: What about the campaign: HIV is a gay disease? Who was the audience and where were these ads placed?

Les: This campaign was just launched, and the target audience has been LGBT people. The ads have appeared in gay publications. There is a billboard as well but that doesn’t use the phrase HIV is a gay disease.

Question: Is humor ever used in campaigns and is it helpful?

Liz: There is much less humor in US campaigns. In Europe it’s different. In Great Britain, there is an “HIV positive people are not invisible” campaign that uses humor. There is a French campaign where people hold four leaf clovers while involved in different sex acts. Kaiser has been very puritanical in its campaign, and is not measuring their effectiveness.

Julie: One positive thing is that Kaiser/Viacom are working condoms into TV sitcoms.

Question: Are TV spots and narrowcasting still a gold standard for social marketing?

Les: TV is still the gold standard and the Internet is also good sometimes. A lot of people don't go to gay bars or read gay papers, so why not use TV? Moving images can also get across a message more powerfully.

Kevin: Folks should be able to turn on the TV and see behavior interaction being modeled- using condoms, seeing mothers and fathers having conversations with transgender kids, etc.

Julie: A bus ad is designed to speak directly to small segment of population, but your audience is the entire city of Philadelphia, in addition to your target audience. What is narrow casting and what is an appropriate assessment?

Question: What about stigma? We need to challenge social marketing campaigns to be accountable and not just being “controversial.” Let's think about the “Not Fabulous” campaign. It is using the fear of stigma- a fear that your photo will be plastered on subway station if you’re positive. The use of controversy to generate discussion is good, but at the end of the day there is a responsibility to ensure that when you use stigma in that way, it needs to actually address the reality of stigma and discrimination against HIV positive people in our society.

Les: The men that are in those ads are real people. They’re saying: “This is me, this is what I’m dealing with, and this sucks,” in selfless ways. If people see this, what might or could happen to them, then that will wake them up. I don't see it as stigmatizing; I see it as a reality. We're not making anything up here, and we're not saying anything bad about those people. They're really speaking in their own voices and basically saying: “My experience with this disease is a miserable, difficult thing that I don't wish on anybody. If me coming out on a billboard will stop someone else from getting the disease, it’s worth it.” There was a forum on this campaign in California because of all the controversy. People who were in the ads were in the audience (and other people called the images of them grotesque). The stigma comes from externalizing agents--people who look at them and have negative reactions. It gets to this kind of airing our dirty laundry thing. There are certainly trade-offs and pros and cons. The intended consequence is that young gay men who don't give a shit about HIV all of a sudden realize that they should.

Kevin: There is a question of truth and reality. At what point does being socially responsible come into this issue? Think about marketing campaign with black men hanging from trees to get the point across of what HIV is doing. Would that even go up? If HIV affected a less marginalized group of people, the types of campaigns we would have would be really different.

Comment: I like the Kenneth Cole campaigns, and I like the Aldo campaigns. And it’s powerful for me as a black man to see Will Smith saying, “We all have AIDS.” You have to touch other people by telling your story. If one person makes a change because of I decided to tell my story, that is what matters. In the Not Fabulous campaign, there's a black guy in diapers—I thought that was so sexy, unbelievable, and courageous.

Comment: How can we make sure we are relevant to our community? We got a great response from young people of color on the Aldo ads. Artists and celebrities can move young people to have conversations. I think those messages can have an impact on communities in ways that we think may often not work. We took it to the Hip Hop Summit and it was culturally relevant and made a difference.