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Health Communication and Social Marketing Campaigns for Sexually Transmitted Disease Prevention and Control: What Is the Evidence of their Effectiveness?

Friedman, Allison L. MS*; Kachur, Rachel E. MPH*; Noar, Seth M. PhD; McFarlane, Mary PhD*

doi: 10.1097/OLQ.0000000000000286
Review

Background: Despite the ubiquity of sex in the media, a culture of silence surrounds sexual health in the United States, serving as a barrier to sexually transmitted disease (STD) prevention, testing, and treatment. Campaigns can increase STD-related knowledge, communication, and protective behaviors. This review assesses the effectiveness of STD prevention and testing campaigns in the United States to inform the field on their use as a strategy for affecting behavior change.

Methods: A comprehensive literature search was conducted to identify original research articles, published between 2000 and 2014, which report on US media campaigns promoting community- or population-level STD testing or prevention behaviors and are evaluated for impact on one or more behavioral outcomes. Titles and abstracts were independently reviewed by 2 researchers.

Results: The review yielded 26 articles representing 16 unique STD testing and/or prevention campaigns. Most campaigns were developed using formative research and social marketing or behavioral theory. Most campaigns (68.75%) used posttest-only or pretest-posttest designs without comparison groups for evaluation; only 5 campaigns used control groups, and these proved challenging (i.e., achieving necessary exposure and avoiding contamination). Nearly all campaigns found differences between exposed and unexposed individuals on one or more key behavioral outcomes. Several campaigns found dose-response relationships. Among evaluations with uncontaminated control groups whose campaigns achieved sufficient exposure, sustained campaign effects were observed among targeted populations.

Conclusions: Current findings suggest that campaigns can impact targeted STD-related behaviors and add to the evidence that greater exposure is associated with greater behavior change.

From the *Division of STD Prevention, Centers for Disease Control & Prevention (CDC), Atlanta, GA; and †School of Journalism and Mass Communication, University of North Carolina at Chapel Hill, NC

Conflicts of Interest and Sources of Funding: None declared.

Correspondence: Allison Friedman, MS, Centers for Disease Control and Prevention (CDC), 1600 Clifton Rd, NE Mail Stop E-44, Atlanta, GA 30333. E-mail: alf8@cdc.gov.

Received for publication January 26, 2015, and accepted March 26, 2015.

Notes: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Sexually transmitted diseases (STDs) are a serious public health problem in the United States, with more than 20 million cases each year,1 costing the nation more than $16 billion in medical costs.2 A lack of information, misperceptions about STDs, and biological and social influences can place individuals at risk for acquiring or transmitting STDs.3–6 Stigma, embarrassment, fear, and access barriers compound the issue and can affect STD care-seeking and treatment behaviors.3,7,8 The culture of stigma and silence surrounding sexual health in the United States stands in stark contrast to the ubiquity of sex in the media, advertising, and pop culture.3,7,9,10 Consumers are bombarded with hypersexualized messages and portrayals of sex that downplay its risks and complexities and perpetuate traditional sex roles and stereotypes.11,12 Health communication (HC) and social marketing (SM) campaigns can serve as structural interventions, altering the media environment by counterbalancing existing messages, increasing visibility of the consequences of sexual risk behavior, and creating normative perceptions and expectations around sexual health.13 They can also serve as advertising and public-relations efforts to promote an STD program's services and image (respectively).

Campaigns may be broadly defined as strategically planned communication and marketing activities “directed at a particular population for a particular period of time to achieve a particular goal.”14,15 With the potential ability to reach large segments of at-risk populations at low cost per person, campaigns can have far-reaching impact, both directly on individuals exposed to them and indirectly by conversations with those exposed and changes in norms.10,15,16 When strategically designed, implemented, and evaluated, HC and SM campaigns can effectively promote STD prevention and testing norms and behaviors among at-risk audiences, particularly when the target population is well defined and the necessary resources are available to manage a comprehensive effort.10,17–19

To effect individual or social change, communication and marketing strategies must be research-driven and audience-centered, that is, strategically designed based on the audience's values, needs, concerns, and motivations.15,20 Both HC and SM campaigns are developed through an iterative process of research, planning, implementation, evaluation, and refinement. However, they differ in important ways. Health communication campaigns are based on communication and behavioral theory; they use communication messages and tools as the strategy to inform and influence individual and community decisions that impact health.15 However, they cannot influence behavioral outcomes if significant systemic or environmental (access) barriers exist. In contrast, SM campaigns apply marketing principles, using communications as a promotion strategy, but also leveraging product, place, and pricing strategies to bring about behavioral or social change.20 Thus, SM campaigns may alter the “product” or behavioral offering itself, including how, when, and where it is offered, to make adoption easier for target audiences. For example, they may offer incentives or address structural conditions, such as increasing the accessibility of condoms; altering the branding, location, service offerings, or design of STD testing centers to reduce stigma and maximize patient privacy and access; or offering STD tests that are less invasive, faster, and easier. Although HC campaigns may apply the concepts of SM to their messaging and dissemination strategies (e.g., reframing the way a behavior is positioned), they do so using communications alone.

Common elements of successful HC and SM campaigns have been documented elsewhere (Fig. 1). For the purpose of this article, we will hereafter refer to these efforts simply as “campaigns,” without distinguishing their conceptual approach.

Campaigns promoting discrete, one-time behaviors (e.g., vaccination) tend to have greater success than campaigns promoting habitual or socially/interpersonally mediated behaviors.10,15,18 Campaigns have been found to have small-to-moderate effects on sexual risk behaviors (including condom use), with an average percent change of 4% to 6%, which can translate into meaningful population impact.18,21 There is also evidence for the effectiveness of campaigns aimed at reducing one's number of sex partners, promoting safer-sex discussions, and HIV testing.10,19 However, many of these campaigns targeted HIV prevention/testing, which audiences may perceive and respond to differently than other (non-HIV) STD campaigns.22,23 Moreover, previous reviews have typically examined HIV prevention campaigns in a global context, although campaigns in developed countries, such as the United States, may be less effective than those in developing countries.24 This may be because developed countries often have media-rich environments in which consumers are bombarded with scores of advertisements through multiple media channels. In developing countries, there are typically many fewer communication channels competing for attention, making it easier to reach large proportions of the population with a media message.

To date, no reviews have focused exclusively on the effectiveness of STD prevention and testing campaigns in the United States. This review seeks to fill that gap by describing the STD campaigns being implemented and evaluated in the field, and whether they are reaching or impacting intended populations. It attempts to identify both the level of financial investment required to achieve impact and the campaign elements associated with “success,” with the goal of informing STD programs on whether and when HC or SM campaigns may be effective prevention strategies.

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MATERIALS AND METHODS

A comprehensive search of the literature was conducted in February 2014 to identify relevant articles published between 2000 and 2014. Databases searched included PubMed, PsycInfo, Communication and Mass Media Complete, Embase, ABI Inform, and 5 social sciences databases (Applied Social Sciences Index and Abstracts, ProQuest Social Science Journals, ProQuest Sociology, Social Services Abstracts, and Sociological Abstracts). A combination of search terms was used, including “sexually transmitted diseases/prevention and control,” “sexually transmitted infection,” “sexual behavior,” “mass media,” “marketing,” “health education,” “health promotion,” “health behavior,” and “campaign.” A follow-up search was conducted in March 2014, using keywords to retrieve articles still in-process or missed during the initial search.

Titles and abstracts were independently reviewed by 2 researchers for the following inclusion criteria:

1. Manuscript reports on a campaign that uses media channels (including mass, small and social media and/or the Internet) to promote community/population behavior change at the national, state, or community level. Studies involving the exposure of individuals to media programming in controlled settings (e.g., clinic or school) were excluded from review.

2. Campaign focuses on STD testing or prevention behaviors, including condom use, sexual risk reduction (delayed sexual initiation, reduced number of partners), and/or interpersonal communication about STD prevention. Given that SM, by definition, seeks to influence behavior for the greater social good, STD campaigns focused solely on awareness or attitude change were excluded from the review. This ensured a more homogenous set of campaign studies whose primary goal was to change behavior—our primary outcome of interest. Campaigns focused on HIV, hepatitis, vaccination, or pregnancy prevention were excluded unless they included STD messaging and/or outcomes.

3. Study reports original research on one or more behavioral outcomes to assess impact. Review or summary articles were excluded, as they report limited information about individual campaign design or evaluation methods. Articles focused solely on formative research (i.e., exploratory, qualitative, and message testing) or process evaluation were also excluded.

4. Campaigns implemented in the United States and published (in English) in 2000 or later were included.

Finally, we reviewed the reference lists of articles included in the review to ensure that all relevant articles were captured in our search, adding articles that met our inclusion criteria.

Database searches resulted in 714 unique abstracts, from which 37 articles were initially identified as potentially relevant and subsequently retrieved and reviewed. Of these, 16 articles were excluded as they did not meet inclusion criteria. Key reasons for exclusion were as follows: outside United States (n = 3), review articles or single studies with no specific outcomes reported (n = 3), condom distribution programs without media (n = 1), hepatitis or vaccination campaigns (n = 2), formative or process evaluations (n = 3), HIV focused (n = 2), and/or editorials (n = 2). Four additional articles were identified from reference lists of included articles, and 1 article (previously in press) was identified by authors.

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RESULTS

The review yielded a total of 26 articles, representing 16 unique campaigns.25–50 When multiple articles reported on the same campaign, all articles were reviewed and the most relevant and complete information was included in the results table. For citation purposes, the first article published is cited when referring generally to the campaign. Key findings from each campaign are summarized in Table 1 and discussed below.

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Campaign Characteristics

The 16 campaigns covered regions of the West, South, Northeast, and nationwide. Half of them were implemented at the county level (n = 8), one-quarter at the city or municipal level (n = 4), and fewer at the neighborhood (n = 3) or national (n = 1) level. Most (n = 10; 63%) were run by state, county, or local health departments, often in coordination with a university, foundation, organization, or community partner. The syphilis campaigns in LA, San Francisco, and South Florida (n = 6) represented one component of their health departments' coordinated syphilis elimination efforts. Five (31%) campaigns were led by universities, in collaboration with clinical partners or funded by government agencies. The one national campaign was a partnership effort between a federal public health agency, a media company, a national health care provider, and a national foundation. Nine campaigns involved the expertise of media, marketing, or communications/technology agencies.

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Campaign Focus, Scope, Offerings, and Duration

Most (69%) campaigns promoted STD testing, including syphilis (n = 8), chlamydia (n = 1), and general STD (n = 2) testing. Four of these campaigns (25%) also promoted prevention behaviors. In total, more than half (56%) promoted STD prevention, primarily through condom use and safer sex behaviors (n = 8) or parent-adolescent discussions of safe sex (n = 1). In addition, 11 campaigns attempted to address underlying sociocultural barriers by reducing stigma and promoting supportive norms for STD prevention, testing, and communication.

Most campaigns offered products or services to support the desired behavior change and address structural barriers. Ten (91%) of the 11 testing campaigns facilitated access to testing through free or low-cost testing promotions, extended clinic hours, testing-locator tools, hotlines, expedited testing and results-delivery processes, free transportation, culturally sensitive services, or new and convenient testing sites (e.g., home-based testing kits ordered online or by phone/text). Testing was incentivized through coupons, contests, and sweepstakes. Five (63%) of the 8 condom or safer-sex campaigns supported condom use through condom distribution programs, free (phone or online) condom ordering, coupons, and incentives.

Of those reporting implementation periods (n = 14), the average campaign duration was 16.4 months. Nearly half the campaigns (n = 6) ran for less than 1 year, 29% ran for 1 to 2 years (n = 4), and another 29% ran for more than 2 years (n = 4). Although most campaign activities were strategically developed prior to implementation, others seemed to develop organically over time, with components added as opportunities arose.

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Audience Segmentation

All but one campaign (NYC Condom) explicitly identified the target audience of their effort. Most (n = 15) targeted various segments of sexually active or at-risk persons, whereas 2 campaigns targeted parents of at-risk adolescents. Most campaigns used one or more demographic variable to segment their intended audience, and a few identified behavioral, sexual orientation, or linguistic segmentation variables. The most common groups targeted by campaigns were men who have sex with men (MSM; n = 8) and youth/young adults (n = 5). Four campaigns specifically targeted Latinos and African Americans within those groups. In some cases, audiences were intentionally not segmented by sex or racial/ethnic demographic variables to avoid stigmatizing particular subgroups. For example, Get Yourself Tested (GYT) and Alabama's chlamydia testing campaigns chose to focus on both male and female youth (of all races). Three campaigns used more sophisticated segmentation variables, such as high sensation–seeking and impulsive young adults.

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Formative Research

Most campaigns (n = 14; 88%) used formative research, either to inform campaign messaging and strategy development or to test concepts, messages, or materials. Formative research was primarily conducted using focus groups, interviews, or surveys with members of the target audience or key informants (n = 12). In other cases (n = 4), input from community advisory groups, informal audience feedback, or data from existing public health activities (i.e., syphilis case interviews and ethnographic assessments) were repurposed to guide campaign efforts. Some campaigns used a combination of these methods to collect data on primary and secondary audiences.

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Use of Theory

Most campaigns reported the application of an SM framework (n = 9) and/or behavioral theory (n = 7) in guiding formative research, message/product strategy, campaign evaluation, or, to a lesser extent, audience segmentation. Behavioral change theories applied included Social Learning/Cognitive Theory (n = 3), theories of Planned Behavior or Reasoned Action (n = 2), the Health Belief Model (n = 2), and Social Ecological Model (n = 1). Four campaigns specified the use of message design models (e.g., Media Practice Model, sensation-seeking targeting, entertainment education, and role model stories) to inform the development of messages. Four campaigns did not specify any theoretical framework.

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Messaging

Eight campaigns were branded with names and logos, which in most cases reflected the desired behavior change. Either the remaining campaigns did not have a cohesive brand, or the brand was not disclosed. Most campaigns (81%) specified a tagline or clear call-to-action related to getting tested (n = 6), using condoms every time (n = 4), calling a hotline (n = 1), or talking about sex/STDs (n = 3). In a few cases, the taglines or calls-to-action were somewhat ambiguous (e.g., protect what's yours), using acronyms (e.g., GYT) or double-entendres (e.g., Get Some) that were intended to be playful, minimize stigma, and maximize uptake. Some campaigns used multiple calls-to-action and/or strategically introduced new calls-to-action at various phases (annually or even monthly) to promote different behavioral goals, respond to emerging needs/knowledge gaps, or keep the campaign fresh (e.g., n = 8).

Among the 11 campaigns that sought to promote positive norms or minimize STD-associated stigma, most (n = 7) used humorous, light-hearted, and/or sex-positive approaches. Others used normalizing messages (n = 1) or calls to action that encouraged open discussions (n = 3) or packaged STD testing within broader, general health issues, such as family or men's health (n = 2). Two campaigns tried a combination of graphic images and alarming messages/statistics, along with humorous or light-hearted messages. Other campaigns used a dramatic approach with real-life scenarios and narratives (n = 2), or took an informational, skills-based approach to model the desired behaviors (n = 1).

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Communication Strategies

Most campaigns (n = 10) used mass-media channels, supported by a Web site, small-media dissemination, on-the-ground promotions, or interpersonal outreach—either in-person or through social media, such as chat rooms, blogs, or Facebook. Most (n = 14) campaigns used advertising, including paid, donated, and/or public-service ads. In some cases (e.g., Alabama Chlamydia Screening, GYT, Healthy Penis, and Stop the Sores), schools, organizations, or television networks refused to disseminate public service announcements (PSAs) due to sexual content, making paid advertising, partnerships and public-relations, or media-advocacy strategies critical. A minority of campaigns used local/celebrity endorsements (n = 2) and produced entertainment programming for online, on-air, or print channels (n = 1).

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Cost

Cost data were provided by 7 (44%) campaigns, although few outlined how costs were allocated. Costs ranged from $60,000 for a 15-month campaign for MSM in targeted neighborhoods of San Francisco,27 to $1,029,318 for a less-targeted, yearlong syphilis campaign in select Florida counties.45 The median cost was $112,857 per year, based on calculated cost per month among campaigns that provided cost and duration/funding period information (n = 6). It should be noted that the scope and completeness of reported costs varied significantly, so this number may not reflect the full costs of formative research, development, staffing, products, promotions, and evaluation. It also does not differentiate between startup and existing efforts, or campaign length, scope, goals, and strategies.

Some programs maximized resources by sharing development costs and evaluation tools with one another (e.g., Healthy Penis, Stop the Sores, and South Florida's syphilis campaign), or by customizing existing national campaign products for local implementation (at ≤$20,000).29 Several campaigns saved costs through earned, in-kind or donated media time, and resources/staffing (e.g., Safer Sex, GYT, Healthy Penis, Stop the Sores).

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Process Evaluation: Measuring Exposure

Most campaigns (n = 14) tracked audience exposure, although they varied widely in how this was measured. Exposure was most commonly measured through audience self-reported assessments, using aided awareness or recall (recognition of the campaign based on the campaign name, brand, slogan, ads, or products). Some campaigns used more rigorous assessments, such as unaided awareness/recall (using open-ended questions to identify the campaign name or slogan based on recall of topic-related ads or messages; n = 4) or confirmed awareness/recall (through demonstrated knowledge of campaign content; n = 2). A minority of campaigns measured recall of (any) STD prevention/testing messages in the media (n = 2) or relied solely on media network estimates to approximate the proportion of the target audience reached (n = 1).

For the purpose of this review, campaign exposure was defined using audience awareness or recall of campaign content, messages, or products, or, when such data were unavailable, by estimated media reach. We calculated the range and average exposure levels of campaigns. When a campaign reported multiple exposure levels over time, an average exposure level was calculated and used in this analysis. When a campaign reported exposure levels by media channel, average high and low levels were calculated for this analysis. Overall campaign exposure or awareness (including combined aided and unaided awareness levels, when reported) ranged from a low of 18.3% for a national campaign28 to a high of 96% for a targeted citywide campaign,43 with an average of 66.2%. Several campaigns (n = 5) reported higher campaign recall among highest-risk audience segments (e.g., HIV-positive MSM). As expected, aided awareness (14%–68.5%) was generally higher than unaided awareness (18%–37%) and confirmed campaign knowledge (16.9%–30.4%). False recall rates (assessed by 2 campaigns using control groups) ranged from 10% to 14% and varied by channel of exposure.36,43 Among the campaigns that measured exposure by channel, reported recall was higher for television than radio or billboard ads.38,50 One campaign demonstrated that television advertising significantly extended the effects of a mail outreach intervention to prompt interest in chlamydia testing.25 Five campaigns also captured frequency of exposure, but variations in reporting precluded our ability to make useful comparisons.

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Outcome Evaluation

Most evaluations assessed behaviors through surveys or interviews with target audiences (n = 12). As noted in Table 1, measures of self-reported behavioral outcomes varied considerably, even among campaigns with similar behavioral goals. For example, condom use was measured by the number of unprotected sex encounters, frequency of condom use, condom use at last sex, or recent condom use (among other measures), within varying periods. Other evaluations tracked testing outcomes at participating sites (n = 5), either as stand-alone or supplemental evaluations. Many also assessed information-seeking or theoretical mediators (e.g., knowledge/attitudes) of behavior change, but those were not analyzed as part of this review. Only one campaign tracked STD outcomes through specimen collection36; however, these data were not reported or used to validate reported behavioral outcomes.

Most (68.75%) campaigns included in this review did not use experimental comparison groups, using either cross-sectional posttest-only designs (n = 9) or cross-sectional pretest-posttest designs (n = 2). Five campaigns (31.25%; 3 of which promoted prevention and 2 of which promoted both testing and prevention) used more rigorous designs, including 2 quasi-experimental, cross-sectional, pretest-posttest control-group designs, and 3 randomized controlled evaluations with matched media and nonmedia cities or neighborhoods. These evaluations have higher internal validity, although they are also limited by self-report and recall bias.51

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Campaign Effects

STD Testing

Among the 2 testing campaigns (both of which also targeted prevention behaviors) that used more rigorous, pre-post designs with control groups, neither found significant effects on testing behaviors when comparing media to control communities. In one case, the authors acknowledged that the campaign did not achieve sufficient exposure in media communities (<40%) to affect community-level outcomes45; the other evaluation found a high level of contamination in the control community, which limited researchers' ability to detect effects.44 When researchers restricted their analyses to exposed versus unexposed individuals, both campaigns found significant positive associations with testing by level of exposure.

Among the 5 testing campaigns evaluated with post-only or pre-post designs but no comparison group, 3 (60%) found significant increases in testing by exposure at 1 or more time points, including 2 that found associations with sustained behavior change for 2 years.30,48 [It should be noted that one campaign (Check Yourself) found significant differences only among those with confirmed awareness]. One campaign (that promoted general health tests for men with the primary goal of increasing HIV testing) found significant differences for HIV testing but not for STD testing.32 These data are supported by campaign tracking data, which demonstrated evidence of testing uptake as a result of campaign efforts or promotions.25,28,39,46,49 Those reporting STD outcomes yielded positivity rates consistent with or above nationally reported rates,25,28,46,49 suggesting that they reached at-risk individuals.

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STD Prevention

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Condom Use and Sexual Risk Reduction

Among the 5 campaigns that evaluated impact on condom use or sexual risk reduction behaviors using a comparison group, 3 found positive and significant differences between media and control communities.37,43,44 Two of these campaigns found sustained campaign effects throughout their duration, which persisted even after the campaigns had ended.37,43 Although effects began to wane after 3 months after the campaign,43 condom use remained higher than control communities or otherwise projected,43 as much as 18 months after the campaign.37 Media campaigns were found to augment the effects of stand-alone condom distribution programs44 and to augment and extend the effects of community STD screening and counseling programs.38 The 2 campaigns that found either limited or no effects when comparing media to control groups were limited by methodological weaknesses or implementation challenges, including contamination of control communities42 and low exposure in media communities,45 which limited their ability to detect effects. These campaigns found significant differences when comparing exposed to unexposed individuals in separate or post hoc analyses.

Two prevention campaigns were evaluated without control groups. One (which used cross-sectional samples) found varying and sometimes counterproductive effects on prevention behaviors by audience segment and over time,33 but positive and significant effects when comparing those exposed and unexposed to the campaign.32 The authors acknowledged methodological weaknesses in collecting independent samples, as well as a potential bias introduced by another community intervention taking place at baseline. The second campaign found high rates of branded condom use among those aware of the campaign or who had seen the condoms,40,41 but did not assess condom use among those unaware or unexposed, limiting their ability to assess campaign effectiveness.

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Open Communication

The one campaign that promoted safer-sex discussions between parents and their adolescents found a significant, positive association between campaign exposure and frequency of sex talks in the past 6 months, as well as intentions to talk among parents who had not already done so.50 The strongest association was found for exposure through television channels (PSAs).

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DISCUSSION

The following discussion addresses key research questions with the goal of offering useful guidance for STD programs, based on a review of 16 campaigns. It is acknowledged that these findings may not represent the “typical” campaign in the field, which may not get evaluated for behavioral impact or reported in the peer-reviewed literature.

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What Types of Campaigns Have Been Implemented in the Field?

Campaigns were almost evenly split between those promoting testing and condom use, with one-quarter promoting both behaviors. Nearly half were part of comprehensive syphilis elimination efforts. Most campaigns targeted MSM, youth, and/or racial/ethnic-minority audiences. Most campaigns used multiple mass-media channels, supported by on-the-ground or interpersonal efforts, and access to condoms and testing services. Only one campaign addressed underlying sociocultural barriers as a primary goal, although most did attempt to promote supportive norms/environments or minimize STD-associated stigma as a secondary goal. This normalizing approach suggests a shift in the field from earlier STD/HIV campaigns, which have been criticized for exploiting audiences' fears, stigmatizing STDs and those affected, and failing to address underlying STD prevention barriers.3,5,7,52

Most campaigns in this review could be categorized as SM efforts, with 10 (91%) of the 11 testing campaigns and 5 (63%) of the 8 prevention campaigns offering (or altering) a product, service, or policy to facilitate the desired behavior change. This is encouraging, as it reflects a recognition in the field of the importance of altering the physical or structural environment, as well as the media environment, to support behavior change.10,20 Although most were designed and implemented using HC or SM principles, some had very broad or poorly defined audience segments, had too many behavioral goals to be achievable, did not enlist the expertise of communication/advertising experts; lacked a comprehensive strategy or brand, and showed no evidence of strategic messaging design, segmentation, or targeting. Most reported using a SM framework or behavioral theory to guide efforts, but it was sometimes unclear how these were applied. Few reported using message design frameworks for the development of persuasive messages. These findings are largely consistent with those of a previous HIV-campaign review.19

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Were Campaigns Effective in Reaching Intended Audiences and Achieving Desired Behavior Changes?

Campaigns reached, on average, 66% of their target population, which is comparable to recent HIV campaigns (52%–77%; 59%)19,24 and represents an improvement over earlier campaigns.53,54 Exposure levels should be interpreted with caution, given the complexities, variability and validity of measurements.55 Nonetheless, this review suggests that campaigns can reach high-risk audiences, who may not otherwise be reached through health services.

Similar to previous findings, most campaigns in this review used weak evaluation designs that relied on correlational data without control groups.19,22,24,51,56 However, campaigns are increasingly making efforts to enhance the rigor of real-world evaluation designs to improve validity and reliability. Nearly all campaigns found differences between exposed and unexposed individuals on one or more key behavioral outcome. This should be interpreted with caution, particularly for testing campaigns, because exposure to a campaign might occur during testing, thereby confusing cause and effect. Indeed, post-only designs may yield larger effect sizes than more rigorous designs.57 Despite limitations with correlational data, syphilis campaigns were credited (at least in part) with declines in syphilis cases in the early 2000's in San Francisco and LA,30,39,42 where a resurgence was observed after the termination of campaigns.47 Several campaigns found dose-response relationships between the frequency of exposures or number of channels/products to which audiences were exposed and targeted outcomes (South Florida Syphilis Coalition [SFSC], Bull et al., Ross et al., Talk to Kids),42,44,45,50 adding to the evidence that greater exposure is associated with greater behavior change.17,18,58 The wide variability in measurement and design makes it difficult to estimate the typical effects of these campaigns.19,22,53,56

One-third of campaigns attempted to evaluate their efforts using a control group, although this proved to be methodologically challenging. Most efforts could not prevent contamination in control communities or afford to deliver the campaign with sufficient intensity to achieve needed exposure levels in intervention communities. Among those evaluations with uncontaminated control groups whose campaigns achieved sufficient exposure, sustained campaign effects were observed among targeted youth throughout their duration, persisting months or years after the campaigns ended.37,43 It is worth noting that these campaigns were implemented as interventions by academic researchers/institutions. Evaluations that used a control group also suggest that campaigns can augment and extend the effects of other (stand-alone) public health programs, including condom distribution and community STD screening/counseling programs.38,44

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What Level of Investment Is Required to Yield a Measurable Community Impact?

It is difficult to assess the level of investment needed for impact, given the wide variability of campaign scope/strategies and because most campaigns did not document cost data or elucidate components covered. A previous review of syphilis campaigns, based on interviews with health department staff found that annual expenses ranged from $45,000 to $119,000, most of which was typically spent on media placement/dissemination.59In the current review, calculated annual costs of original community/county-level campaigns ranged from $48,000 to $1.12 million. [This does not include local GYT campaigns, which adapted an existing national effort.] However, cost did not necessarily reflect quality, reach, or impact. The most costly campaign spent heavily on promotions but did not invest in communications expertise for strategy or message development, nor did it achieve desired results.45 Other efforts were able to customize existing campaigns to meet local needs for as little as $20,000.29

Although most campaigns ran for over a year, some ran for 6 months or less, some of which noted a lack of funding and need for sustained support.29,45,47 In addition to financial resources, implementers must consider investments in staff capacity/time and partnership development for community buy-in.29,30,45,46,48 To date, no research has assessed the cost-effectiveness of (non-HIV) STD campaigns, and such analysis was not possible based on available data from this review. Studies focused on HIV prevention have found mass-media and condom availability campaigns to be the most cost effective structural interventions for HIV prevention.13,60 Experts have also suggested that campaigns may be more cost-effective than clinical interventions.18

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What Components Contribute to “Success”?

The wide variations in strategies, weak assessment measures, and lack of evaluation of individual components make it difficult to gauge success or tease out the relative effectiveness of campaign components from this review.19,22,53 Previous meta-analyses and efforts have identified elements of success, including audience involvement, communication expertise/training, alignment of message content with target audience, multiple channels, policy or service support, and sustained/sufficient funding 18,24,54,57,59,61 (see Fig. 1). Given that success will vary by audience, context, and time, we have instead highlighted key findings that may help guide future programmatic efforts, drawing from this and previous reviews/meta-analyses.

Some campaigns found that television was more effective than other traditional media channels,25,50 although the relative effectiveness of channels is likely to change with the rapidly evolving media landscape. Certainly, the use of multiple mass-media channels, supported by interpersonal efforts, may increase exposure and likelihood of impact.17,58 This has become easier and more affordable with social media and new technologies, and perhaps more necessary given the increasing diversity of media channels available to audiences. Programs can now reach audiences with tailored information, anonymous services, and interpersonal outreach using digital and social media that eliminate barriers of access, stigma, distance, and time17,49,62,63; however, programs may need assistance in effectively engaging their audience(s) through these channels.29

Programs that invested in community, media, and private-sector partnerships were able to minimize resistance to sexually explicit campaigns and sustain campaigns, even with limited public health funding.29,30,43,45,46,48 Partnerships with other STD Programs can help maximize resources by sharing development costs and evaluation tools with one another, or customizing existing campaigns to local jurisdictions.

Evidence from the more rigorously evaluated campaigns included in this review suggests that well-designed campaigns (which incorporate elements noted in Fig. 1), delivered over extended periods of time, can have long-lasting impact on target audiences, particularly on youth, who are beginning to develop sexual health habits.37,43 Sustained efforts may be needed for meaningful behavioral impact,45,47 particularly for complex behaviors and when competing social norms and media messages are pervasive.10,17 However, this may vary by context, target behavior, audience, and quality of campaigns. Evidence from meta-analyses is mixed on whether longer campaigns are more effective than shorter (≤1 year) campaigns.24,57 It may be that “pulsed” campaigns can offer a successful hybrid, delivering intensive but episodic waves of messages over time.64–66 When feasible, this may not only extend the duration of campaigns but facilitate evaluation (with clearly defined before, during, and after campaign periods).

Rigorous campaign evaluations are costly and difficult, given the geographic scope of campaigns, challenges isolating independent effects, and tensions between research and real-world implementation.10,17,51 Successful controlled studies were those run by universities with intervention and control communities in different states, highly segmented audiences and targeted (single radio or television) channels, paid media to guarantee exposure in intervention communities, and multiple, short-term assessment periods (at 3-month intervals) to detect effects.35–38,43 In contrast, less successful control studies were conducted within the same state (using zip codes, cities, or counties as the unit of analysis), used less-targeted segmentation and dissemination strategies, relied on small-media or donated PSAs (which cannot guarantee or control exposure), and often used longer timeframes (>6 months) to assess outcomes, when effects may have diminished.42,44,45 Given that the impact of a campaign is a function of both its efficacy and reach,67 implementers must balance the allocation of funds to ensure campaign quality, reach, and intensity, adjusting scope, duration, and evaluation efforts as appropriate. Too often, real-world constraints (i.e., community needs, time, funding, and institutional review board delays) trump good intentions for rigorous research.

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Limitations

This review focused on behavior change campaigns with impact data. It may not have captured most typical campaigns, which are neither evaluated for impact nor published in the literature. It did not capture general awareness campaigns without specific behavioral goals, nor did it assess knowledge or attitudinal changes, which may be important predictors of sexual behavior and norms (e.g., stigma). However, the review was very rigorous in that it focused primarily on the outcome of behavior change, the key public health outcome that HC and SM campaigns often seek to impact.

This review did not examine process measures beyond exposure, which limited our ability to assess specific campaign components or activities. Furthermore, the wide variations in campaigns and evaluation designs made it impossible to conduct a meta-analysis to tease out which elements contributed to success. Finally, this review did not include campaigns aimed at providers or policymakers, which may be critical for promoting health care services/access and policies influencing sexual health.

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Conclusions, Gaps, and Future Efforts

Figure. No caption a...

Campaigns can promote STD prevention and testing behaviors in at-risk populations and complement the effects of other public health programs. Health communication/SM campaigns may fill a gap in STD prevention efforts when there are known social or behavioral contributors to the STD problem, which could be modified through changes in a defined population's attitudes, norms, or behaviors; when that population is not otherwise being reached by STD-Program efforts; and when sufficient resources are available to develop, implement, and sustain them. [Note: campaigns may also be used for advocacy purposes, to promote policy change; however, this was the focus of the current review.] In addition to shifting behaviors, campaigns are also being used to shift cultural norms that hinder STD prevention (e.g., stigma). They could offer effective strategies for addressing other upstream determinants (e.g., sex inequities, stereotypes, and discrimination against sexual minorities), which could have ripple effects on STD prevention.5

Although some campaigns are making efforts to do so, more rigorous research is still needed to strengthen the evidence base for campaign effectiveness. Design elements can be incorporated into real-world efforts to reduce threats to internal validity.68,69 When possible, researchers should use multiple measures of exposure, including unaided and aided recall, and include a fake campaign name/ad/product in aided-recall questions to capture false recall.55 Lessons learned from the few evaluations with control groups suggest that threats to contamination can be minimized by selecting a control community that is geographically separate from the intervention community, with a distinct media market. When a control group is not feasible, multiple methods can be used to increase confidence in observed effects—such as tracking STD testing data, conducting precampaign and postcampaign surveys, and comparing local data to broader trend data. Although any evaluation is better than no evaluation, standard evaluation measures are needed to compare STD testing/prevention campaigns and estimate the magnitude of effects.

More research is also needed to identify which elements lead to campaign success and which strategies are most effective for specific populations. Additional documentation of implementation details (such as funding amount, duration, setting characteristics, and process evaluations of campaign activities) would enable practitioners to assess the level of effort invested in campaigns and their relative success. Novel approaches may be needed to evaluate new and evolving channels, such as social and digital media.62 Cost-effectiveness analyses of campaigns are also greatly needed. Quantifying the cost savings is challenging but achievable70 and necessary to prioritize HC/SM campaigns against other STD intervention strategies. Finally, future efforts should assess unintended consequences of a campaign,71,72 which typically go unmeasured but are critical considerations when targeting vulnerable populations with sensitive content.

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