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

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.

An assessment of the GYT: Get Yourself Tested campaign: an integrated approach to sexually transmitted disease prevention communication.

BACKGROUND: Youth in the United States bear a disproportionate burden of sexually transmitted diseases (STDs). Stigma, misconceptions, and access challenges keep many from getting tested or treated. The GYT: Get Yourself Tested campaign was launched in 2009 to reduce stigma and promote STD communication and testing. This evaluation sought to assess the first 2 years of campaign engagement and associations with STD testing among youth. METHODS: Campaign engagement with select GYT on-the-ground events, social media sites, and STD testing locator tools was measured through process/media tracking metrics. Sexually transmitted disease testing patterns were assessed using data from Planned Parenthood affiliates (2008-2010) and national trend data from clinics participating in national infertility prevention activities (2003-2010). RESULTS: On-the-ground events reached an estimated 20,000 youth in 2009 and 52,000 youth in 2010. Across 2009 to 2010, GYT's Facebook page gained 4477 fans, Twitter feed gained 1994 followers, and more than 140,000 referrals were made to the STD testing locator. From April 2008 to 2010, there was a 71% increase in STD testing and a 41% increase in chlamydia testing at reporting Planned Parenthood affiliates (representing ∼118 health centers). Chlamydia case positivity rates during this period were stable at 6.6% (2008) and 7.3% (2010). Trend data indicate that testing was higher in spring 2009 and 2010 compared with other periods during those years; this pattern is commensurate with STD Awareness Month/GYT activities. CONCLUSIONS: Data quality is limited in a manner similar to many STD prevention efforts. Within these limitations, evidence suggests that GYT reaches youth and is associated with increased STD testing.

Preparing for human papillomavirus vaccine introduction in Kenya: implications from focus-group and interview discussions with caregivers and opinion leaders in Western Kenya.

BACKGROUND: Cervical cancer claims the lives of 275,000 women each year; most of these deaths occur in low-or middle-income countries. In Kenya, cervical cancer is the leading cause of cancer-related mortality among women of reproductive age. Kenya's Ministry of Public Health and Sanitation has developed a comprehensive strategy to prevent cervical cancer, which includes plans for vaccinating preteen girls against human papillomavirus (HPV) by 2015. To identify HPV vaccine communication and mobilization needs, this research sought to understand HPV vaccine-related perceptions and concerns of male and female caregivers and community leaders in four rural communities of western Kenya. METHODS: We conducted five focus groups with caregivers (n = 56) and 12 key-informant interviews with opinion leaders to explore cervical cancer-related knowledge, attitudes and beliefs, as well as acceptability of HPV vaccination for 9-12 year-old girls. Four researchers independently reviewed the data and developed codes based on questions in interview guides and topics that emerged organically, before comparing and reconciling results through a group consensus process. RESULTS: Cervical cancer was not commonly recognized, though it was understood generally in terms of its symptoms. By association with cancer and genital/reproductive organs, cervical cancer was feared and stigmatized. Overall acceptability of a vaccine that prevents cervical cancer was high, so long as it was endorsed by trusted agencies and communities were sensitized first. Some concerns emerged related to vaccine safety (e.g., impact on fertility), program intent, and health equity. CONCLUSION: For successful vaccine introduction in Kenya, there is a need for communication and mobilization efforts to raise cervical cancer awareness; prompt demand for vaccination; address health equity concerns and stigma; and minimize potential resistance. Visible endorsement by government leaders and community influencers can provide reassurance of the vaccine's safety, efficacy and benefits for girls and communities. Involvement of community leadership, parents and champions may also be critical for combatting stigma and making cervical cancer relevant to Kenyan communities. These findings underscore the need for adequate planning and resources for information, education and communication prior to vaccine introduction. Specific recommendations for communication and social-marketing strategies are made.

Promoting sexual health equity in the United States: implications from exploratory research with African-American adults.

In an effort to inform communication efforts to promote sexual health equity in the United States, the Centers for Disease Control and Prevention sought to explore African-Americans' perceptions of the sexually transmitted disease (STD) problem in their communities, reactions to racially comparative STD data and opinions about dissemination of such information. Semi-structured triads and individual interviews were conducted with African-American adults (N = 158) in the Southeastern and Midwestern United States. Most participants believed that STDs are a problem in their communities but were unaware of the extent to which STDs disproportionately affect African Americans. Once informed about racial differences in STD rates, participants commonly reacted with shock, fear and despair; a minority raised questions about the information's source and credibility. Most felt it was critical to get the information out to African-American communities as a 'wake-up call' to motivate change, though some raised concerns about its dissemination. Findings suggest that information about racial differences in STD rates must be strategically crafted and delivered through targeted channels to be acceptable to African Americans. So as not to further harm communities burdened by other social/health inequities, alternative (strength-based) approaches should be considered for motivating positive change.

Exploring the feasibility of alternative STD-testing venues and results delivery channels for a national screening campaign.

UNLABELLED: Annual chlamydia screening is recommended for sexually active women aged 25 years and younger, though less than half of eligible women are screened each year. If acceptable to young women, nontraditional testing venues and new communication technologies could promote efficiencies in sexually transmitted disease (STD) screening and facilitate screening by overcoming barriers at systems and patient levels. OBJECTIVE: This study sought to explore young women's technology use, preferences for STD-testing venues, attitudes toward nontraditional venues, and acceptability of test results delivery options. METHOD: A total of 80 ethnographic one-on-one telephone interviews were conducted with African American, Caucasian, and Latina women, aged 15 to 25 years, in 10 metropolitan areas of the United States. Interviews were recorded, transcribed, and analyzed using NVivo2. RESULTS: Alternative STD-testing venues and results delivery channels are valued by young women for their convenience and accessibility, but they must also offer privacy, confidentiality, and emotional/informational support to be acceptable. Assuring provider (or self) competence and valid/accurate test results is also important. CONCLUSIONS: Although new technologies have been embraced by young women for personal and social uses, they may not be as readily embraced for the provision of STD-related services. Additional social marketing efforts may be needed to promote acceptance of nontraditional STD-testing settings and results delivery methods.

Experiences and Views of Domestic Summer Travelers During the COVID-19 Pandemic: Findings from a National Survey.

Domestic travel creates a serious risk of spreading COVID-19, including novel strains of the virus. Motivating potential travelers to take precautions is critical, especially for those at higher risk for severe illness. To provide an evidence base for communication efforts, we examined the experiences and views of travelers during the summer of 2020 through a telephone survey of 1,968 US adults, conducted in English and Spanish, July 2 through July 16, 2020. The survey found that more than one-quarter (28%) of adults had traveled domestically in the prior 30 days, most commonly for "vacation" (43%), and less than half wore masks (46%) or practiced social distancing (47%) "all of the time." Although high-risk adults were significantly less likely to travel than non-high-risk adults (23% vs 31%; P < .001), they were no more likely to take precautions. Many travelers did not wear a mask or practice social distancing because they felt such actions were unnecessary (eg, they were outside or with friends and family). Although a substantial share of travelers (43% to 53%) trusted public health agencies "a great deal" for information about reducing risks while traveling, more travelers (73%) trusted their own healthcare providers. Findings suggest that outreach may be improved by partnering with providers to emphasize the benefits of layering precautions and provide targeted education to high-risk individuals. Messages that are empathetic to the need to reduce stress and convey how precautions can protect loved ones may be particularly resonant after more than a year of pandemic-related restrictions.

Views and Experiences of Travelers from US States to Zika-Affected Areas.

Travelers to areas with Zika virus transmission are at risk of infection and of transmitting the virus after returning home. While protective behaviors during and after travel can reduce these risks, information about traveler practices or underlying views is limited. We examined these issues using data from the first representative poll of travelers from US states to Zika-affected areas, including US territories and Miami, Florida, conducted December 1 to 23, 2016. We analyzed results among all travelers (n = 1,285) and 2 subgroups at risk for pregnancy-related complications: (1) travelers in households where someone was pregnant or considering pregnancy (n = 72), and (2) other travelers of reproductive age (n = 631). We also examined results among those with different levels of awareness and knowledge about Zika virus. Results show that in households where someone was pregnant or considering pregnancy, awareness of Zika in the destination, concern about infection, and adoption of protective behaviors was relatively high. That said, sizable shares of travelers as a whole did not know information about asymptomatic and sexual transmission or post-travel behaviors. Further, concern about getting infected during travel was low among travelers as a whole, including other travelers of reproductive age. Few travelers consistently adopted protective behaviors during or after travel. Even among travelers who were aware of Zika in their destination and knew how to protect themselves, adoption of protective behaviors was only slightly higher. Findings from this poll suggest communications may be more effective if tailored to different levels of true and perceived risk. To address gaps in knowledge about transmission and post-travel protective behaviors, messaging should include facts and acknowledge the complexities of novel information and social context. Consideration should also be given to emphasizing other benefits of Zika protective behaviors or prioritizing behaviors that are most feasible.

Exploring the knowledge, attitudes, beliefs, and communication preferences of the general public regarding HPV: findings from CDC focus group research and implications for practice.

Genital human papillomavirus (HPV) infection is the most common sexually transmitted virus in the United States, causing genital warts, cervical cell abnormalities, and cervical cancer in women. To inform HPV education efforts, 35 focus groups were conducted with members of the general public, stratified by gender, race/ethnicity, and urban/rural location. Focus groups explored participants' knowledge, attitudes, and beliefs about HPV and a hypothetical HPV vaccine as well as their communication preferences for HPV-related educational messages. Audience awareness and knowledge of HPV were low across all groups. This, along with an apparent STD-associated stigma, served as barriers to participants' hypothetical acceptance of a future vaccine. Although information about HPV's high prevalence and link to cervical cancer motivated participants to learn more about HPV, it also produced audience fear and anxiety. This research suggests that HPV- and HPV-vaccine-related education efforts must be approached with extreme caution. Other practical implications are discussed.

Reaching Youth With Sexually Transmitted Disease Testing: Building on Successes, Challenges, and Lessons Learned From Local Get Yourself Tested Campaigns.

Nine programs were funded across eight states in the United States to customize, implement, and evaluate local campaigns in support of the national Get Yourself Tested (GYT) campaign. Each program promoted chlamydia screening and treatment/referral to sexually active young women (aged 15-25 years) and their partners through accessible, free, or low-cost services. This article documents the strategies and outcomes of these local GYT campaigns, highlighting the diversity in which a national sexual health campaign is implemented at the local level and identifying challenges and successes. Nearly all (n = 7) programs involved target audience members in campaign development/implementation. Youth were linked to free or low-cost sexually transmitted disease testing through community centers, high schools and colleges, community and clinic events; online or text-based ordering of test kits; and community pickup locations. Sites used a combination of traditional and new media, on-the-ground activities, promotional products, and educational and social events to promote testing. With the exception of one site, all sites reported increases in the number of persons tested for chlamydia during campaign implementation, compared to baseline. Increases ranged from 0.5% to 128%. Successes included development of local partnerships, infrastructure, and capacity; use of peer leaders and involvement; and opportunities to explore new innovations. Challenges included use of social media/new technologies, timing constraints, limited organizational and evaluation capacity, and unforeseen delays/setbacks. Each of these issues is explored, along with lessons learned, with intent to inform future sexual health promotion efforts.

Unveiling the hidden epidemic: a review of stigma associated with sexually transmissible infections.

Stigma has long accompanied sexually transmissible infections (STI) and hindered prevention and control efforts. It not only acts as a formidable barrier to STI testing, treatment and disclosure, but has a multitude of consequences for the health and quality of life of infected individuals. This review summarises the literature related to STI stigma and offers practical approaches to counter STI-associated stigma through multi-level efforts. Specifically, it describes the key sources that breed and perpetuate stigma, outlines how STI-associated stigma has been conceptualised and measured in the literature, documents the impact of stigma on infected and uninfected individuals, and summarises the stigma reduction strategies recommended in the literature. Gaps in the literature are identified and areas for further research are suggested, along with practical strategies for moving forward.

'Clinics aren't meant for men': sexual health care access and seeking behaviours among men in Gauteng province, South Africa.

Men may be key players in the transmission of sexually transmitted infections (STI), and it is important that STI/HIV health services reach men. The objective of this study was to explore sexual health care access and seeking behaviours in men. This study used focus groups to examine sexual health care access and seeking behaviours in men 5 years after implementation of free antiretroviral therapy (ART) in the South African public sector. Six focus groups (N=58) were conducted with men ≫18 years in an urban area of Gauteng province. Men were recruited from various locations throughout the community. Men reported several barriers and facilitators to the use of public and private clinics for sexual health services including HIV testing, and many men reported seeking care from traditional healers. Men often viewed public clinics as a place for women and reported experiences with some female nurses who were rude or judgmental of the men. Additionally, some men reported that they sought sexual health care services at public clinics; however, they were not given physical examinations by health care providers to diagnose their STI syndrome. Most men lacked knowledge about ART and avoided HIV testing because of fear of death or being abandoned by their families or friends. Study findings suggest that men still require better access to high-quality, non-judgmental sexual health care services. Future research is needed to determine the most effective method to increase men's access to sexual health care services.

"something we'd rather not talk about": findings from CDC exploratory research on sexually transmitted disease communication with girls and women.

BACKGROUND: Chlamydia is a leading cause of pelvic inflammatory disease (PID), which can lead to ectopic pregnancy, chronic pelvic pain, and infertility. Annual Chlamydia screening is recommended for all sexually active women aged ≤ 25 years, yet only about 40% of eligible women are screened each year in the United States. To promote Chlamydia screening for the prevention of infertility, the Centers for Disease Control and Prevention (CDC) is developing direct-to-consumer efforts for sexually active young women and key influencers. To inform this effort, CDC sought to explore girls'/women's understandings of sexually transmitted disease (STD) and Chlamydia testing and STD communications and information sources. METHODS: Two waves of one-on-one interviews (n = 125) were conducted in 10 metropolitan areas with African American, Caucasian, and Latina females, aged 15-25 years. RESULTS: Most participants were not knowledgeable about Chlamydia or its screening; their discussions about it suggested low levels of perceived susceptibility or relevance to Chlamydia and screening. STDs are rarely discussed in home or social settings or with partners or close friends; yet young women may turn to interpersonal sources if concerned about an STD. Providers are the primary and preferred source of STD information for girls and women, although missed opportunities for engaging young women in STD/sexual health discussions were identified in clinical and other settings. CONCLUSIONS: Providers, family members, friends, and partners may serve as important intermediaries for reaching young women and encouraging STD/Chlamydia screening. Resources are identified that could be leveraged and/or developed to facilitate such interactions.