Take Charge. Take the Test.
The Centers for Disease Control and Prevention implemented a one-year social marketing campaign in Cleveland (OH) and Philadelphia (PA) to increase HIV testing in African American women at high risk for HIV infection.
Launched in 2006, the ‘Take Charge. Take the Test.’ campaign promoted HIV testing and information seeking through telephone hotlines; a website; community partnerships; events; and print, radio and outdoor advertising.
- Over 200 partners in both cities contributed significantly to campaign efforts.
- Key informant interviews indicated that due to increased coordination, city infrastructures for HIV testing improved.
- More than 9,600 individuals attended a total of 48 campaign events, with 1,492 rapid HIV tests administered and 14 newly-identified HIV individuals. Overall, event attendees responded positively to campaign events and free HIV testing opportunities.
- The campaign significantly increased information-seeking behaviours in the form of hotline calls and web searches.
- Audience reaction and receptivity to the final campaign materials was very high. Exposure to campaign messages was associated with increases in key knowledge items, intentions to get tested and peer-to-peer communication.
Although the rate of new HIV infections has levelled off among certain US populations, infection rates are rising in other populations, partly due to the estimated 21 per cent of persons living with HIV who remain unaware of their status. Up to two-thirds of new HIV infections are transmitted by persons who do not know they are infected. Helping these persons learn early about their HIV infection can help them get early access to treatment. Prompt medical care is proven to help delay the onset of AIDS and prevent some life-threatening conditions. Furthermore, some studies show that persons who learn they have HIV then adopt risk reduction behaviours, such as increased condom use, which can prevent spreading HIV to others. Also, HIV positive individuals who receive HIV-related medical treatment should have a decreased viral load, which is associated with decreased HIV transmission.
Previous social marketing HIV prevention campaigns have resulted in small but significant changes in target audience members’ knowledge, attitudes and behaviour. In 2003, Centers for Disease Control and Prevention (CDC) had launched the initiative ‘Advancing HIV Prevention: New Strategies for a Changing Epidemic’, to facilitate early diagnosis of HIV infection and increase access to treatment and prevention services to reduce the incidence of HIV.
To support this initiative, in 2004 CDC formed a planning team to initiate a campaign to increase timely HIV testing (meaning within three to six months after possible exposure) among high-risk populations in the US. Timely HIV testing and early diagnosis allows for those with HIV to receive counselling, access life-lengthening therapy, and prevent further HIV transmission to sexual partners and unborn children.
Funding and support for the campaign was provided by the US Department of Health and Human Services, Office of Minority Health, Minority HIV/AIDS Initiative and the CDC, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Division of HIV/AIDS Prevention, Prevention Communication Branch.
Potential target audiences
With the distinct focus on HIV testing, the team examined existing and supplemental research to begin determining an ideal target audience. Further review of findings from in-depth individual interviews, existing data and key informant research quickly pointed to two potential populations for increased testing: African American adults and men who have sex with men (MSM). These two groups are most affected by HIV/AIDS in the US, as reflected in incidence, prevalence and mortality trends over time.
Half of all new HIV infections in the US occur among African Americans, despite only making up 13 per cent of the US population. They also account for more of the estimated number of persons living with AIDS and more deaths among persons with AIDS than any other racial/ethnic group. Further, using CDC surveillance data available near the time of campaign development revealed HIV was the third leading cause of death for African Americans aged 25 to 34 in 2001, compared with the sixth leading cause of death for whites and Hispanics in this age group.
While MSM account for the largest number of AIDS cases, the team decided to focus on the African American population because research available at the time of campaign development indicated that:
- Despite persistent high-risk behaviours, MSM were getting tested more regularly than other groups; the challenge for MSM was to maintain HIV prevention strategies and regular testing.
- By contrast, fewer African Americans, regardless of gender, were getting tested for HIV regularly, with many unaware of the alarming HIV trends in their population group.
Segmenting the market
Because of a limited budget, combined with differences across segments of the African American community, the team determined that further audience segmentation and prioritisation was needed. Subsequently the African American community was further segmented by age, gender and sexual behaviours. This revealed five segments for further evaluation:
- African American men aged 18 to 34 who have sex with men only
- African American men aged 18 to 34 who have sex with men and women
- African American men aged 18 to 34 who have sex with women only
- African American single women aged 18 to 34 who have sex with men only (one or more partners)
- African American married women aged 18 to 34 who have sex with men only
Each segment was evaluated according to:
- HIV/AIDS incidence
- Risk behaviours
- Current testing behaviours
- Ability to be reached
- Ability to be influenced
- Potential to influence others
Since quantifiable data for most of these factors were not available for these five segments, the planning team engaged in additional rigorous efforts to fill in knowledge gaps:
- Review of existing literature, including relevant journal articles and books, CDC’s Behavioural Risk Factor Surveillance System database, published surveys and findings from research conducted for prior campaigns
- Focus groups and in-depth interviews with members of potential target markets
- Interviews with key informants, including those with special expertise regarding African Americans and HIV testing, and social marketing professionals
- Consultation meetings, including forums with representatives from advocacy groups, health institutions and faith-based organisations.
After evaluating these data, and by cross-referencing the PRIZM segmentation system by Claritas (a national syndicated research database that defines markets based on distinct demographic, psychographic, lifestyle and regional characteristics), the following group emerged as the clear choice for the campaign target audience:
- Single African American women aged 18 to 34
- With some college education or less
- Earned US$30,000 or less per year
- Resided in certain zip codes with high HIV-prevalence
- Were having unprotected sex with men
Understanding the target audience
Once the primary audience was selected, the team used a variety of methods to develop a richer understanding of this audience, beginning with a review of prior research studies conducted with young African American women.
The CDC then convened a consultation to learn how to best proceed with the campaign with representatives from community-based organisations, government and public health institutions, and national organisations that serve African Americans.
The team also conducted extensive focus groups and individual interviews with African American women in Philadelphia (PA), Chicago (IL), Dallas (TX) and New Orleans (LA), to learn about the women’s: values and priorities; knowledge, attitudes, behaviours, barriers and motivators related to HIV testing; preferred television channels and radio stations; and key influencers.
- Belief that testing will be expensive and time consuming
- Belief that good, affordable treatment is not available
- Unaware of facilities for testing
- Belief that HIV testing is part of annual physical
- Fear of being positive
- Fear of rejection from family and community if found to be positive
- Loss of insurance and/or employment if results reported to government/state authorities
- Anxiety about waiting for results
- Low perception of personal risk
- Concern and uncertainty over whether a partner is being faithful and/or if heard something about a current or previous partner
- Desire to be present and available for children
- Desire to protect others and limit further HIV transmission (if found to be positive)
- Peace of mind and ability to control one’s life and future
- Potential to receive earlier treatment if found to be positive
- Everyday priorities and burdens outweigh concerns about HIV
- Strong ties to family and local communities exist
- Faith/religion is an important part of everyday life
- Most common reasons for engaging in unprotected sex were: financial dependence on male partners; feeling invincible; low self-esteem and need to feel loved by a male figure; alcohol and drug use
- Everyday priorities (such as employment and childcare) outweigh concerns about HIV, or allow little free time to travel to an HIV testing site
- Alternative facilities for HIV testing, including private healthcare providers
Theoretical framework considerations
Before developing campaign strategies, the team selected a theoretical framework to guide decision-making. Three behavioural models were identified as most relevant to addressing challenges and opportunities of the selected target audience.
The Ecological Model
This model posits that individual behaviour changes are influenced by more than personal knowledge, beliefs and attitudes, but also by the individual’s peers, community leaders, organisations and communities.
Theory of Planned Behaviour
This theory suggests that intention to perform a behaviour, such as HIV testing, is influenced by beliefs, attitudes and norms surrounding the behaviour, and perceived behavioural control. The team interpreted a person’s ability to overcome external barriers to HIV testing as self-efficacy.
Health Belief Model
This model predicts that behaviour change readiness is affected by perceptions of risk, benefits and barriers, and cues to action.
These three models were ‘blended’ to create the campaign’s theoretical framework. The proposed theoretical framework and corresponding formative research findings were presented at a consultation with health communication, social marketing, and evaluation experts. Feedback from these experts was incorporated into the framework that follows.
Aims (final intended outcomes for the target audience)
- Increase the percentage who get an HIV test
- Increase the number of individuals who become aware they are living with HIV
- Increase the number who report getting an HIV test after exposure to the campaign
- Increase the percentage who intend to get tested for HIV within six months
Objectives (intermediate outcomes for the target audience)
- Increase knowledge of the importance of getting an HIV test within three to six months after unprotected sex
- Increase knowledge of HIV serostatus
- Increase the percentage who believe they should be tested for HIV because they are at risk
- Increase the percentage who believe it is important for women like them to get an HIV test
- Increase the percentage who believe that community resources and HIV treatment are available to them, if needed
For the target audience to get an HIV test within three to six month after having unprotected sex with a male partner.
The team sought to develop a marketing mix that would emphasise the danger to women of their partners’ risky behaviour and minimise the perceived difficulty of being tested for HIV.
With the target audience in mind, the team developed the product platform first, considering the three traditional levels of a product:
- Core product: Peace of mind and the benefits of early detection, such as earlier treatment
- Actual product: Getting an HIV test within three to six months after having unprotected sex with a man
- Augmented product: Rapid HIV tests; a toll-free line and website for identifying free HIV testing locations; access to prevention counselling services; access to treatment and support resources for people with HIV; and an informational booklet about HIV/AIDS and HIV testing, including specific information on the importance of timely HIV testing
Perceived costs of getting an HIV test were kept ‘top-of-mind’ during strategic planning. Foremost among these were the stigma of living with HIV/AIDS, wait time for results, costs for testing and treatment, and time to get to testing locations.
Monetary incentives included an emphasis on providing free HIV tests. Non-monetary strategies were addressed by other components of the marketing mix, with rapid tests as part of the Product, convenient distribution channels as part of Place, and normative messaging as part of Promotion.
Given the perceived value of time, the team ensured convenient testing in targeted communities at public clinics, health facilities, private physician offices, community-based organisations and community events. Distributors in these settings were also identified as key, with an emphasis on various trusted and reliable HIV testing providers (public and private) to promote desired behaviours, distribute campaign materials and provide HIV tests at the most convenient locations.
The key message was based on a ‘look out for yourself’ theme, with an emphasis on the risky behaviour that can lead to getting HIV and the empowerment that comes with getting tested – ‘You feel as if you’ve known him forever, but that doesn’t mean you know everything. Get an HIV test and look out for yourself’.
This was paired with a message noting that women may be at risk as a result of their partners’ risky behaviours, and they can take control by deciding to get tested. Supporting messages described the scope of the problem among African American women, the similarity to the target audience (i.e., two out of three African American women with AIDS contracted HIV through unprotected sex with a man), and the availability of free tests and convenient resources in their communities. Normative messages reinforced that other African American women were getting tested for HIV.
Once draft messages and concepts were produced, it was essential to understand how the target audience perceived them. Three stages of focus groups and individual interviews were conducted with African American women in various cities, during which campaign elements such as the campaign name, ‘Take Charge. Take the Test.’ (TCTT) and the campaign logo were refined and finalised.
- Free rapid HIV testing provided at most events
- Distribution of promotional materials
- Events were held at public venues, such as parks and churches in each campaign city. Events featured speakers, campaign spokespeople, entertainment, information and vendor booths, and free HIV testing
- The TCTT campaign promoted free telephone hotlines to assist individuals in accessing HIV/AIDS information and finding free testing sites in each city
- A campaign website was promoted on advertisements and materials
- The website allowed users to search for free HIV testing locations by specific zip codes and provided information on the basics of HIV/AIDS infection, HIV prevention strategies and living with HIV infection
The communications campaign aimed to increase risk perception and motivate HIV testing in the target audience through the following channels:
- A suite of printed materials, including posters, an educational booklet, and tabletop display and signage for community events and health fairs
- Paid advertising on radio and out-of-home locations (billboards and transit)
- Direct mail postcards announcing community events
Partnerships with local health departments, public and private HIV testing locations, and members of national HIV/AIDS and African American organisations to assist with establishing relationships within the local communities and help identify local partners.
Local coalitions and partners were provided with two training sessions – one-on-one grant writing and one-on-one planning an event – to equip them with tools and skills to support the campaign and empower them for future programmes.
To avoid competition from alternative facilities for HIV testing, the campaign worked with all public testing centres that offered free HIV testing in the zip codes where the target audience lived. These centres were promoted via the website, hotline, materials and city spokespeople. However, private testing locations were not promoted.
Grassroots community outreach
Local or on-the-ground support for community outreach in each city was supported by a city coordinator, someone who resided in that community and had knowledge about HIV/AIDS and the target audience. He/she:
- Liaised with the local health department, local coalition/partners, CDC and Porter Novelli (an international public relations agency)
- Distributed campaign materials
- Hosted or supported events
- Acted as a visible presence in the community during the campaign
Originally there were only plans to hold one event in each city. However, following the success of the initial events a number of subsequent events were held in each city. A particularly successful event was the ‘Summer Solstice’ event in Philadelphia, which was developed by TCTT and local stakeholders, including:
- Healthy Start (community-based maternal and child health programmes, particularly addressing infant mortality, low birth weight and racial disparities in perinatal outcomes)
- Circle of Care (family-centred care and services for HIV affected women, children, adolescents and their families)
- AIDS Activities Coordinating Office (AACO)
The event featured music and entertainment; offered onsite HIV testing inside and outside (in mobile units); displayed partner and community organisations’ information at stands; and was attended and endorsed by a local radio celebrity and woman living with HIV.
“During the research we learnt that women wanted to hear from women like them, so we had a spokesperson in each city who was living with HIV who would come to events and speak about their lives and let people know that they were living a healthy life. That was very powerful.” (Jami Fraze, CDC)
Print advertising ran eight times in the three weeks prior to the event in the local African American community paper, Philadelphia Tribune, alongside radio advertising and partnerships with two local hip-hop stations. Radio advertising played a key role in encouraging women to attend the event.
“Our involvement with the radio stations turned out to be very helpful because people would come to the events, we’d be having testing on site, and it might be in a public park on HIV testing day, and people would come and say they’d heard about it on the radio and they wanted to be tested.” (Jami Fraze, CDC)
There were approximately 185 attendees, most of whom were young African American women. 106 individuals were tested for HIV and one positive individual was identified. In addition, the event brought community organisations together and attendees responded positively to the event and requested more like it.
A number of events in Cleveland had to be rescheduled due to the fact that counselling services were not offered on Fridays or Saturdays. However, seeing the need for counselling on these days, a positive policy change was made to introduce counselling on these days. Initial resistance from the religious community subsided when an influential minister at a prominent church publicly announced support for the campaign, which brought others from the church community on board.
“Some leaders in the religious community were hesitant to support HIV testing with this target audience from a church perspective, but there was a big turnaround when one of the ministers publicly committed to the cause.” (Jami Fraze, CDC)
The process evaluation assessed the extent to which the campaign was implemented as planned, by examining campaign activities and target audience exposure and receptivity.
- The campaign secured support from 128 partner organisations in Cleveland and 157 partner organisations in Philadelphia. A total of 203 organisations across both cities contributed significantly to the campaign (for instance by distributing promotional materials)
- City coordinators working for the campaign and partner organisations distributed 26,366 TCTT materials in Cleveland and 68,883 in Philadelphia during the campaign
- The campaign delivered a total of 10,168 gross rating points (GRPs) through radio advertisements (5865 in Cleveland, 4302 in Philadelphia), and more than 98 million impressions through print, radio, outdoor and transit media placements
- Cleveland secured 135 value-added media placements and Philadelphia secured 224
- Key informant interviewees perceived city infrastructure for HIV services as adequate in both cities, but working with the TCTT campaign increased organisational coordination, further improving infrastructure
- Structured participant observations conducted at two events per city indicated that attendees appreciated TCTT events, materials and free HIV testing. Most interviewees reported that they had seen or heard TCTT advertisements and would attend future events
The outcome evaluation’s goal was to determine the extent to which the TCTT campaign was effective in changing HIV testing-related attitudes, beliefs, intentions and behaviours in the desired direction. The parameters under which the campaign was implemented posed several challenges for a sensitive evaluation - for instance the absence of a control community or other experimental implementation, timing of campaign launch and duration, and narrowly defined target audience.
To overcome these challenges, the CDC designed a multi-method evaluation to triangulate results from market- and individual-level data sources. Data included campaign event attendance, rapid tests administered at campaign events, hotline call volume, HIV testing location searches on the campaign-promoted website, public centre HIV testing data, and a web-based randomised controlled experiment.
- Average monthly HIV tests in Philadelphia increased from 531 per month prior to the campaign launch to 566 per month (a 6.6% increase) after the campaign launch, which was not statistically significant.
- Overall levels of HIV tests reported in the Cleveland public testing center data increased from 73 per month prior to the campaign to 101 per month (a 38.4% increase) after the campaign launch, which is a statistically significant increase (p<0.001). However, since HIV testing was already following an upward trajectory prior to the launch of the TCTT campaign, this increase cannot be attributed to the campaign.
- The campaign participated in 48 events (21 in Cleveland, 27 in Philadelphia), with more than 9,600 attendees.
- 1,492 rapid HIV tests were administered at campaign events and 14 HIV-positive cases were identified.
- Statistical trends showed that the campaign launch was associated with a noteworthy upward shift in hotline calls (calls per month increased 308 percent in Cleveland and 13 per cent in Philadelphia during the campaign). Increases in intensity/dose of radio advertising were strongly associated with increases in call volume.
- In each city, testing location searches through www.hivtest.org rose significantly over time during the campaign. Increases in intensity/dose of radio advertising were significantly associated with testing location searches.
- Receptivity to TCTT messages and materials was very high. Exposure to TCTT messages was associated with increases in key knowledge items targeted by the campaign, increases in 6- and 12-month intentions to be tested for HIV, and increases in peer-to-peer communication about getting an HIV test.
Upon completion of the campaign in both cities, the CDC held a ‘thank you’ event in each city to show its appreciation to partners and stakeholders who had been vital for the campaign’s implementation.
“At the end as we finished in both cities we had a meeting with key partners and stakeholders in each city, and we gave them appreciation plaques. Also through our relationship with the newspaper we placed a ‘thank you’ advertisement in the newspaper.” (Jami Fraze, CDC)
Any materials that remained after completion of the campaign, such as posters and postcards that had numbers specific to Cleveland or Philadelphia, were sent to the relevant cities so they could be used for future local events.
Evaluations and learning from the campaign were shared through a number of published articles. Due to the campaign’s success, the CDC is developing a toolkit for local organisations that outlines the foundations of the campaign and presents best practices for planning, implementation and evaluation.
“What we’ve done is taken some of the best practices from the pilot campaign in Cleveland and Philadelphia and created a toolkit that health departments can use to implement this campaign, and they can do a fully integrated campaign like was done in the pilot cities, or they can customize it to best fit their cities’ resources and needs.” (Jennie Johnston, CDC)
Doing thorough formative research into what motivated the target audience’s behaviour produced actionable insights that were vital to the success of the campaign.
“When you’re getting ready to plan a similar effort, do as much as you can to learn about the target audience and what motivates them to do the behaviour that you need them to do, and try and make it as relevant and lasting and appealing as possible. Even if you have scarce resources, if you can be as methodical and thoughtful as possible, it’ll still go a long way.” (Jami Fraze, CDC)
Working with trusted partners in campaign cities reached more target audience members in a much more influential way than advertising and materials could have alone.
The campaign also appears to have been effective at increasing organisational coordination and further improving the infrastructure for HIV services in both cities, based on findings from the key informant interviews. Interviewees did suggest, however, that the CDC should supply funds to community-based organisations to run TCTT events themselves.
The TCTT campaign spurred the target audiences’ willingness to act in the form of information seeking, which demonstrates behavioural intent, a precursor to behaviour change.
Although there is no evidence to claim the campaign had an impact on HIV testing in the public testing centre setting, a large number of rapid HIV tests were administered during campaign-sponsored events. When considering barriers to different HIV testing settings, the TCTT campaign may have had a greater influence on testing outside the clinic setting, such as rapid testing at local events. However it must be noted that when testing outside of clinics it is important to ensure a thorough system of record keeping is followed to aid monitoring and assessments.
Campaign messages may motivate the target audience to find out more about HIV testing and attend events if testing is free and convenient, but not necessarily planned and scheduled. Expanding the number and reach of rapid testing events may have substantial potential to measurably increase testing behaviours.