To the Editor:
Over the past 25 years, more than 50 social and behavioral interventions have been developed, evaluated, and shown to be efficacious for one or more populations at high risk of infection with human immunodeficiency virus (HIV) or another of the many sexually transmitted diseases (STD).1 With so many behavioral interventions available for so many populations at risk for so many STD in so many different places in the United States, program managers have difficulty deciding which intervention—or combination of interventions—to choose. “Dogs are talking”2 stimulated our thinking about this problem and a possible solution.
“Dogs” was another in a series of “social marketing campaigns” conducted over the past decade to reverse trends in infectious syphilis among men who have sex with men.3 Importantly, most men diagnosed with infectious syphilis had been shown to be infected with HIV and were under treatment, report many anonymous sexual partners, and often meet their sexual partners through the Internet. As Kerani et al discovered in Seattle,4 and we found in south Florida,5 “social marketing” in conjunction with other activities might have increased “awareness,” but it failed to do the things necessary to interrupt disease transmissions.
To the list of failures proposed by Fenton and Wasserheit6 we offer:
* Failure to identify the problem of resurgent syphilis as primarily limited to a relatively small and well-characterized group of HIV-infected men receiving antiretroviral therapy and meeting anonymous partners through Internet websites.
* Failure to choose the intervention best suited to address the problem, such as educational outreach to physicians treating men who have sex with men for HIV disease to promote frequent testing and “cluster testing” for syphilis and other STD.
* Failure to apply social marketing theory properly.7 Social marketing must be driven by the needs of “the audience,” not the needs of campaign sponsors. Too much attention has been given to just one of the 4 p's: “promotion.” Not enough attention has been given to product, price, and place.
To program managers, we recommend the following:
* Adopt health promotion planning models, such as PRECEDE/PROCEED,8 to identify the appropriate intervention package for a well-defined behavioral concern within a particular population, such as reducing unprotected sexual intercourse among men who have sex with men likely to be infected with or exposed to infectious syphilis.
* Conduct formative research to define, refine, and frame the problem, and use the results to tailor interventions to the priority population and specific behaviors to be modified.9
* Once the decision has been made to introduce a health promotion program, continue assessments to make sure interventions are being implemented with integrity.
Social marketing has proven to be an effective method of inducing behavior change, but it—as all other available interventions—must be used properly.10 Social marketing should not be expected to be effective in STD prevention when it is used to solve a problem for which it is not well suited. Health promotion planning models, formative research, and intervention mapping provide useful tools for selecting, developing, and implementing appropriate behavioral interventions for HIV/STD prevention.
Susan Biersteker, Drs
William W. Darrow, PHD
Department of Health Promotion and Disease Prevention
Robert R. Stempel College of Public Health and Social Work
Florida International University
1. Centers for Disease Control and Prevention. Evolution of HIV/AIDS prevention programs—United States, 1981–2006. MMWR Morb Mortal Wkly Rep 2006; 55:597–603.
2. Stephens SC, Bernstein KT, McCright JE, et al. Dogs are talking: San Francisco's social marketing campaign to increase syphilis screening. Sex Transm Dis 2010; 37:173–176.
3. Vega MY, Roland EL. Social marketing techniques for public health communication: A review of syphilis awareness campaigns in 8 US cities. Sex Transm Dis 2005; 32(suppl 10): S30–S36.
4. Kerani RP, Handsfield HH, Stenger MS, et al. Rising rates of syphilis in the era of syphilis elimination. Sex Transm Dis 2007; 34:154–161.
5. Darrow WW, Biersteker S. Short-term impact evaluation of a social marketing campaign to prevent syphilis among men who have sex with men. Am J Public Health 2008; 98:337–343.
6. Fenton KA, Wasserheit JN. The courage to learn from our failures: Syphilis control in men who have sex with men. Sex Transm Dis 2007; 34:162–165.
7. Daniel KL, Bernhardt JM, Eroglu D. Social marketing and health communication: From people to places. Am J Public Health 2009; 99:2120–2122.
8. Green LW, Kreuter MW, eds. Health Promotion Planning: An Educational and Ecological Approach. 4th ed. New York, NY: McGraw-Hill, 2005.
9. Kok G, Schaalma H, Ruiter RA, et al. Intervention mapping: Protocol for applying health psychology theory to prevention programmes. J Health Psychol 2004; 9:85–98.
10. Randolph W, Viswanath K. Lessons learned from public health media campaigns: Marketing health in a crowded media world. Annu Rev Public Health 2004; 25:419–437.