Friedman, Allison L. MS*; Brookmeyer, Kathryn A. PhD*; Kachur, Rachel E. MPH*; Ford, Jessie MS*; Hogben, Matthew PhD*; Habel, Melissa A. MPH*; Kantor, Leslie M. MPH†; Clark, Elizabeth MA†; Sabatini, Jamie MSW‡; McFarlane, Mary PhD*
There are an estimated 20 million incident sexually transmitted diseases (STD) annually, half of which occur among youth aged 15 to 24 years.1 However, many youth do not receive the services needed to detect and treat STDs and prevent further transmission.2 Numerous individual, social, and structural challenges prevent STD testing and treatment among youth. These include a culture of silence and stigma, which not only inhibits access to services but also hinders STD information seeking, open communication, and STD disclosure.3–6 A Centers for Disease Control and Prevention (CDC) study released in March 2008 indicated that 1 in 4 teen girls had an STD.7 In response, the national GYT: Get Yourself Tested campaign was launched in April 2009 (STD Awareness Month) to promote STD testing among sexually active youth 25 years and younger.
Campaign Background and Development
GYT is produced through a partnership between MTV, the Kaiser Family Foundation, and Planned Parenthood Federation of America (PPFA). The CDC has provided assistance to ensure scientific accuracy of GYT’s health information. Each of these agencies mobilizes its media, communication, and public relations resources through teams of 2 to 6 existing staff members.a Campaign strategies were informed by formative research4,8,9 and key constructs of the Health Belief Model10 and the Theory of Planned Behavior.11 Formative research revealed that many youth are unaware of the asymptomatic nature and pervasiveness of STDs, that routine STD screening is advised, or that confidential, noninvasive, and youth-friendly services are available. Youth often do not perceive themselves to be at risk for STDs and fear various aspects of STD testing (e.g., uncomfortable procedures and what others will think and say).4,9 Although providers, family members, friends, and partners emerged as important intermediaries for reaching youth, opportunities to engage youth in discussions about STDs are often missed in clinical, school, and home settings.12 Campaign messages were therefore developed to increase STD awareness and perceived risk, reduce fear and stigma, and promote open communication with sex partners and health care providers.
GYT uses television, Web, print, short message service (SMS), and on-the-ground efforts to reach youth with information and link them to testing. The hub of the campaign is the Web site www.GYTNOW.org (Fig. 1). Through this site, as well as an SMS locator tool, youth can access nearby, free/low-cost, and teen-friendly STD testing services ( www.findSTDtest.org). National promotions and celebrity endorsements further incentivize testing. The GYT campaign runs year-round, with refreshed messaging each April. GYT toolkits containing promotional materials are provided each year to facilitate state and local efforts.
In its first 2 years, the campaign primarily drove youth to the Web site, with a limited presence on Facebook and Twitter. Sexually transmitted disease testing was promoted across platforms and through partners’ on-the-ground efforts. In year 1 (2009), on-the-ground activities relied predominantly on local Planned Parenthood health centers and advocates. By year 2 (2010), the campaign had expanded its partner base to include school-based health centers, state and local health departments, community organizations, colleges and universities, and high schools. GYT toolkit distribution increased from 1500 in year 1 to 4000 in year 2. Evidence from select local sites suggests that on-the-ground GYT efforts are associated with increases in testing at participating health centers, schools, and community organizations.13–15 A 2010 consumer mail survey of teens indicated that awareness of the GYT campaign had reached 18.3%; some respondents (10%–21%) reported that GYT prompted information seeking or discussions about STDs/testing with a sex partner, family member, friend, or provider.16 However, this survey assessed only a subset of GYT’s intended audience and was unable to link reported campaign exposure to behavioral outcomes.
This article presents the first available national evaluation of GYT-associated youth engagement and STD testing during the campaign’s first 2 years. Two major factors have inhibited a rigorous evaluation. First, GYT is produced through existing, in-kind resources from key partners and various state and local organizations. Second, national dissemination precluded randomized approaches to testing community-level effects (exposure cannot be controlled). Instead, we have tracked campaign reach and effectiveness through available data sources. We have measured changes in STD testing at select partner health centers nationwide, observed national testing patterns during that same period, and examined national trend data to assess if patterns of testing cohered with GYT’s peak promotion period and STD Awareness Month activities (April). Although each data source is limited with respect to establishing effectiveness, a consistent pattern of GYT’s “fingerprints” across multiple independent data sources provides some convergent validity for the campaign. Evaluation findings help to identify challenges and successes that can inform other sexual health prevention efforts.
MATERIALS AND METHODS
Three data sources were used to assess the first 2 years of campaign engagement and associations with STD testing and communication. These include event and media tracking metrics, STD patient data from PPFA health centers during the campaign’s major promotion period (April), and national trend data from clinics participating in national infertility prevention activities.
Campaign Tracking (Media Metrics)
Campaign reach and engagement in 2009 and 2010 were tracked through youth participation at Planned Parenthood–affiliated events in April, GYT Facebook fans, and GYT Twitter followers. Tracking metrics also gauged the GYT pledges made during a collegiate Facebook contest during the month of April 2010, and the number of GYT badges unlocked during a Foursquareb promotion during the month of September 2010. In addition, GYT traffic to the STD testing locator was measured.
Patient and STD Testing Data from Planned Parenthood Affiliates
Sexually transmitted disease testing was assessed using data from Planned Parenthood, the campaign’s primary health service provider. In April 2009 and 2010, 69 affiliatesc (representing approximately 850 health centers) consistently reported the number of STD tests run, the proportion of positive tests (test positivity), and patient demographic data. A subset of 9 Planned Parenthood affiliates (representing approximately 118 health centers dispersed across the United States) reported STD testing in April 2008 (precampaign), allowing for a limited pre-post comparison. These data were compared against a national-level data set from family planning settings.17
National Trend Data
To assess the extent to which GYT may affect national testing behaviors, we examined national trend data in chlamydia testing from 2003 to 2010. Data were provided quarterly to CDC by more than 6500 clinics participating in national infertility prevention activities. These data permit an examination of quarterly testing patterns before and after GYT’s peak promotion period.
Data analyses are descriptive for campaign media and event tracking, testing trends at Planned Parenthood affiliates, and national trend data in chlamydia testing. For the subset of 9 Planned Parenthood affiliates that reported 3 years of data, researchers calculated the change from year to year to examine affiliate-level trends from April 2008 (precampaign) through April 2010, comparing the proportion of affiliates reporting testing increases against a null hypothesis of random changes and an alternative of 5% increasesd (guided by chlamydia test numbers in family planning clinics across 2008–2010).17 To examine trends at the affiliate level on a larger scale, the percent change in STD tests performed by 69 Planned Parenthood affiliates in April 2009 and 2010 are described. Analyses used a pre-post evaluation design to examine changes in STD testing before and during the period of the GYT campaign. Percent changes in testing patterns and patient demographics as well as the odds of observing a change from 2008 to 2010 against the null hypothesis of no change were used.
Campaign Tracking (Events and Media Metrics)
In year 1, Planned Parenthood health centers and advocates hosted 450 education and outreach events, reaching an estimated 20,000 youth. Year 2 on-the-ground efforts included 745 events, reaching almost 52,000 youth.
In year 1, the GYT Facebook page gained 2726 likes (fans) and GYT’s Twitter feed gained 1445 followers. A total of 83,404 referrals were made to the STD testing locator from the GYT Web site or SMS code in that same year. At the end of the second year, there were a total of 4477 Facebook fans and 1994 Twitter followers. The number of referrals in year 2 dropped to 61,119, but it should be noted that the testing locator was unavailable to clients of a large mobile network carrier for a portion of this period due to contractual issues.
GYT was also promoted through a Facebook “Campus Challenge” in April 2010, in which 1365 students from 167 schools pledged to get tested during the month. A one-time promotion on Foursquare during September 2010 resulted in 4819 GYT badges unlocked.
Patient and STD Testing Data from Planned Parenthood Affiliates
Three-Year STD Patient and Testing Trends (2008–2010). Data from the 9 Planned Parenthood affiliates from baseline year through the 2 implementation years indicate increases between 2008, 2009, and 2010. There was a 71.0% increase in patients receiving STD testing in April 2010, compared with the same period in 2008 (Table 1). The increases in testing between 2008 and 2010 were in populations deemed most vulnerable to STD infection, including African Americans, Latinos, and people living at or below 150% of the federal poverty level.18 Increases were also seen among youth younger than 25 years, GYT’s target audience (Table 1). Chlamydia testing and test positivity were of particular interest to the campaign, given chlamydia’s high prevalence, potential health consequences, and annual testing recommendations for young women. There was an increase in chlamydia testing of 41.2% among women and 49.9% among men between April 2008 and 2010 (Table 2). Chlamydia positivity from these tests ranged between 5.1% in 2008 and 6.6% in 2010 (Table 2).
Two-Year STD Patient and Testing Trends (2009–2010). Table 3 presents the total number of STD tests performed by 69 reporting Planned Parenthood affiliates in April 2009 and 2010. Planned Parenthood affiliates tested a total of 106,948 patients for STDs in April 2009, compared with 120,370 patients in 2010, a 12.5% increase. The increases in testing were greater in populations most affected by STDs, including African Americans, and for women living at or below 150% of the federal poverty level, although slight decreases were observed in STD testing among white men. Increases were also seen among youth younger than 25 years. Sexually transmitted disease test positivity rates (chlamydia, Table 4) were 5.5% in 2009 and 6.5% in 2010, similar to the national median.19
Probability Analyses (2008–2010). A post hoc probability analysis of chlamydia testing in the subset of 9 Planned Parenthood affiliates providing data between 2008 and 2010 (n = 9) examined the pattern of changes in numbers testing between 2008 and 2010. Analyses indicate that increases in chlamydia testing at the affiliate level were not likely due to chance alone. Between 2008 and 2009, nearly all affiliates (8 of 9) showed an increase in chlamydia testing among women (P = 0.02), and all affiliates showed an increase in chlamydia testing among men (P = 0.002). Between 2009 and 2010, there was no marked pattern of increases; the distribution of testing increases for both sexes was close to what one would expect from random data (4 of 9 affiliates increased for women and 5 of 9 for men, both P > 0.40). Last, between 2008 and 2010 (baseline and implementation year 2), nearly all affiliates (7 of 9) indicated an increase in chlamydia testing among women (P = 0.09), and nearly all affiliates (8 of 9) indicated an increase in chlamydia testing among men (P = 0.02). These conclusions hold for men and women, even if the probability of the observed increases is compared with a 5% increase in testing from 2008 to 2010, although for women, the comparison drops from 7 of 9 to 6 of 9 (both P > 0.05).
National Trends in STD Testing
For 2009 to 2010, trend data from clinics participating in national infertility prevention activities indicate that testing is higher in spring compared with other periods during those years. Since 2003, the number of tests reported is highest in the spring of each year, but also increases across time (Fig. 2). The pattern of increases around April (which is sustained up to the fourth quarter of each year) precedes GYT; however, the trend is clearest in 2009 and 2010. For example, in 2006, the second-quarter peak is high, but the drop-off is steep and seen in the third quarter.
GYT marks the first comprehensive national campaign promoting STD awareness, testing, and communication among youth in the United States. In its first 2 years of implementation, GYT event and media tracking show a growing number of youth engaged with the campaign. A near-doubling of Planned Parenthood on-the-ground activities in year 2 reached almost 3 times as many youth as that in year 1, reflecting both increased youth engagement as well as enthusiasm and uptake of GYT from clinical partners and youth advocates. Online engagement also increased on GYT’s social media platforms, without any paid advertising. Reported metrics do not capture engagement with GYT through partner and celebrity platforms (e.g., social media sites, blogs, YouTube), which are difficult to track but may extend campaign reach. For example, one of GYT’s prelaunch celebrity videos on YouTube attracted more than a quarter million views and generated thousands of comments.
Although there is ample evidence from other campaigns linking consumer awareness and exposure to behavior change,20,21 it is more difficult to assess the value of social media engagement and whether it translates into meaningful behavior change. Research in the area of digital media interventions for the promotion of sexual health has been limited, with better evidence for knowledge changes than for behavior change.22 It is also difficult to gauge the “success” of these efforts, given the lack of other national STD-focused campaigns in the United States. Tracking numbers may be modest relative to other national efforts, perhaps because of limited investment in advertising, or youth’s reluctance to associate with a stigmatized topic. Although GYT’s fan base grew throughout the first 2 years, some of its social media efforts (e.g., Campus Challenge) were met with limited youth engagement. Nonetheless, thousands of individuals were engaged in GYT and may have been influenced to get tested or talk about the issue (i.e., normalizing the conversation). Encouragingly, nearly 145,000 Web and SMS referrals were made to clinics/health centers through GYT during these 2 years, which suggests that users are linking to campaign information, and intending to get tested.
Positive changes in testing behavior were observed in a subset of 9 Planned Parenthood’s affiliates. The number of STD patients visiting these Planned Parenthood affiliates was higher during campaign implementation periods compared with the same period precampaign. Patient demographic data reveal that increases were most notable among GYT’s intended audience (youth) and those at increased risk for STDs, including racial/ethnic minorities and low-income persons. Data from these 9 affiliates are bolstered by data from a broader network of 69 Planned Parenthood affiliates, where testing increased between April 2009 and April 2010, commensurate with greater dissemination of GYT. Importantly, distinct increases were seen among young (<25 years), low-income and minority patients. Through the first 2 years of campaign implementation, STD test positivity rates remained consistent with the national averages reported to CDC,17 indicating that at-risk populations were being reached. These testing increases exceed those observed in family planning clinics nationwide during this same period,17 as well as what would be expected from random chance alone.
Finally, national trend data show that GYT activities occurred with a marked increase in testing in spring 2009 and 2010, which is sustained through most of those years. Interpretation of this finding is open to caution as similar patterns are visible in previous years, although with less clarity. It should be noted that STD Awareness Month activities predated the campaign, albeit on a smaller scale and in a less coordinated manner. It is plausible that raising awareness of STD prevention is generally useful and that GYT is a particularly efficacious version of these activities. The overall rise in chlamydia testing across time is certainly affected by efforts other than GYT (e.g., the HEDIS measure).23
As noted in the “Introduction,” the data sources we have used in this evaluation are limited in that we had to seek evidence of GYT reach and effects in data primarily designed for other purposes. Tracking data were limited to a small number of events, media channels, and resources, not including television and other key channels used to promote GYT. Data described in this report do not explicitly connect campaign exposure to actual STD information-seeking, talking or testing behaviors. We regard these data as a starting point for more sophisticated analyses using data from later years, which will assess the campaign’s impact on youth testing and communication, as well as stigma and theoretical mediators of behavior change.
Data from Planned Parenthood sources and from clinics participating in national infertility prevention efforts may not be representative of all facilities in the United States that test young persons for chlamydia and may be biased toward serving low-income women. The screening criteria and coverage vary by facility, and some may not send data on all tests completed. Moreover, observed increases in testing may have resulted from factors unrelated to GYT. Finally, the specific health centers reporting data may have changed over time due to changes in local programs, which limits the use of approaches such as time series analyses.
There is limited but promising evidence that youth-oriented marketing and normalizing messaging, coupled with links to testing services and on-the-ground promotions, can yield increases in STD testing. Evidence presented here indicates that GYT is reaching youth—prompting dialogue about STDs/testing, linking youth to STD testing resources and services—and is associated with increased STD testing at select testing sites nationwide. Cooperation among public and private sector partners and the use of existing data to measure outcomes may inform other STD prevention evaluation efforts in situations where ability to influence data collection is limited.
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