Session 11- SEXUAL HEALTH
a) Know the risks: Social Marketing for the millennium
Jeffrey Wilkinson & Robert Galante
South Beach AIDS Project, 1234 Washington Avenue, Ste 203, Miami, 33139, USA.
Phone no: +1- 305-532-1033. Fax no: +1 –305-532-1813
E-mail: jnots@ibm.net, info@sobeaids.org
Miami Beach is a very small, relatively concentrated demographic area that is geographically defined because of the central Biscayne Bay. In the early 1990s it was the place to be in South Florida. It also has some interesting characteristics from the standpoint of the evolution of the Southeast Gaming Preservation and national parks. So there are a lot of factors that led up to its rise in popularity.
Even as far back as the early 1990’s, young gay men were coming to South Beach and beginning to settle from all over the US. They were basically in ill-health and were looking to find a location where they could form their own community and party for their last days, going out in a blaze of glory. South Beach soon became known as ‘God’s HIV waiting room’, prior to the advent of protease inhibitors. They came, they saw, they stayed, they moved and before long the word got out throughout the US. People who were HIV positive and were already beginning to experience the first stages of ill health said, "We don’t want to deal with the winters up north. We want to make the rest of our lives as comfortable as possible". Thus a community began to evolve.
The HIV infection concentration within the community of that small geographic area was already designated as high as 35%, right up there with San Francisco, New York and Los Angeles. That is why it was so disturbing that no organisation had been established to address the needs of this population.
The South Beach AIDS Project
The organisation began to address some of the issues. It began with safer sex seminars for the community on a regular basis, dealing with specific health issues and reinforcing the concepts of safer sex in various venues throughout Miami Beach. These offered a forum for the HIV infected population to come together and discuss issues affecting the community. They began outreach work in the clubs. This was not limited exclusively to the gay clubs because the South Beach nightlife, like many larger cities, does interact with the straight community.
The Gay Men’s Health Study
Concurrently FIU, through Doctor William W. Darrow, had begun to undertake a men’s health study on the residents of South Beach. This was done through face to face contact, where people went door to door addressing households, basically to identify people within the community who fitted the targeted population that they were looking to gain information on.
The first portion of the study was carried out with the younger age group of men who have sex with men (MSM), from the ages of 18 to 29. Based on the findings, funding was received through FIU to continue the study to the 30 years plus group. A lot of what the survey brought forth was already known but it needed to be factualised in order to focus on the issues that needed to be addressed.
Some of the numbers were staggering. 205 people were studied in the face-to-face survey and they completed a 30-40 page questionnaire, which ended with anonymous HIV testing using the HIV-antibody test to try and correlate the results. It was found that within the prior 90 days, 92% of the people had engaged in unsafe sex. That was alarming. It was also found that 77% had anal intercourse, of which 45% was unprotected. That is the primary method of HIV transmission among men who have sex with men (MSM).
The study also found that under half stated that they had been drinking alcohol at least once a week. 40% said that they had used cocaine and ecstasy within the past year and over half stated that they had been having anal intercourse under the influence of alcohol and drugs. Therefore, there was a direct correlation between lifestyle and the nightlife that existed in the South Beach community, and what was evolving to be continuous unsafe sex practices.
Since these numbers are so alarming, we decided to do a lot more. Being a privately funded ‘grassroots’ organisation, we had already developed a reputation of being an ‘in your face’ organisation who would address the issues at whatever level and through whatever means necessary. After all, we were not exactly dealing with the most conventional issues compared to other locations in the US. We did not have to answer to anybody. We did not depend upon the Federal Government, State government or local government for funding so they could not pull our money away. That allowed us to assess the needs at the time and to try and address the reasons why people were having unsafe sex when they were basically very knowledgeable. An offshoot of the South Beach Health Survey showed that this was not an uneducated population. It was basically a white, college-educated, very well informed population that knew about HIV and HIV transmission. Yet with all that background and knowledge they were still not following safer sex practices.
With the advent of protease inhibitors in 1997, a major change was taking place. There were wonderful reports in the media that people who were adopting the new cocktail were having some really positive results, but were not factoring their lifestyle into it. People who had come to South Beach from all over the US and maybe some other parts of the world to party till they dropped, now found that they had to deal with issues surrounding the fact they were not going to die so quickly. They had to start thinking about living, re-addressing and changing the focus from dying to living.
Around that time, Patrick Gill had just been elected to the board of the project and, within a week of his election, he dropped dead on the dance floor. He was a member of the community so we knew that he accepted responsibility for his health. He was taking protease inhibitors, but he was also a party boy. We found out through an investigation into various party drugs that something was beginning to happen. Similar patterns were emerging in a lot of the clubs in New York and Los Angeles that had not existed before.
At a conference in Miami Beach the pharmaceutical company presentations contained information based on their pharmacology, which showed that there were some dangerous interactions between HIV medication and party drugs. While they had acknowledged this with the Food and Drug Administration (FDA) process and testament of clinical trials, they had never taken these to the next level: the lifestyle level. It was beginning to show that there was a lack of responsibility and the project set out very belligerently to demand that the information be given by the pharmaceutical companies to the public. The companies sat on this information because there was a liability issue and there were legal aspects that they did not want to address. The project took the lead once again and said, "Give us the information. We will accept the liability portion of this but we will get it out into the community". That was the beginning of the ‘Know the risks’ campaign.
Know the risks
A small media campaign was developed called ‘Know the risks’. The initial stage was to develop and distribute posters, primarily in nightclubs frequented by members of the gay community, but also then branching out to other venues such as shopping stores or restaurants. It was started in August 1997, with specific drug information posters that featured local celebrities, personalities and community members in the message itself. There are ones about ecstasy, GHB, and ‘special K’ (ketamine).
The objectives were:
- at least 60% of the gay men on South Beach would be exposed to the materials;
- at least 80% of those who were exposed would recall the message;
- at least 50% of those exposed would talk to somebody about the message with a view to thinking about changing their behaviour or at least be more informed.
There was an entire wish list and we wanted to develop some other material apart from the posters but it was just not possible, given what was available, as well as the initial reception to the campaign. As the campaign was put together very quickly, there was no opportunity to do focus group testing. As a result the posters were distributed on the tail of a series of raids on the South Beach club community for drugs and/or sex. Therefore, the club owners were very reluctant to put up posters that were not promoting the message of zero tolerance, even though they knew that behaviour continued as it always had in the clubs and bars.
The campaign was evaluated by some postgraduate students. The primary goal was to assess if the message reached the target audience and, if it did, whether they knew what it was about. The evaluation teams looked at four different components. They assessed the actual posters for reading levels, technical accuracy and consistency of information. They held focus groups within the gay community, targeting everyone from adolescents to the HIV positive. They did a process evaluation to determine the exposure of the campaign. They ended with an impact evaluation to estimate the impact of the campaign, and to determine if the objectives were attained.
The assessments found that the colourful photographs of the local celebrities and drag queens attracted attention and interest, but the messages were written at too high a reading level (eighth grade or higher). They were very technical and that it should be taken down to a fifth grade reading level. The messages were written with a font size that was too small, especially for distribution in a bar or club where there may not be good lighting conditions and people may not be coherent when reading. It was too long and too complex and needed to be shorter and more direct.
The results of the focus group were that the campaign was well received by the diverse groups, but that the messages needed to be shorter, more direct and easier to read.
For the process evaluation, people went out into the community to see exactly what bars and clubs the posters were in. They were distributed in February and March and they were only up in 5 of the 16 venues targeted. The reasons for that are twofold. Due to the popularity of the tongue-in-cheek photographs used, people were stealing the posters to take them home. Then there was a manpower issue because there were not enough people to drop in and replenish the posters. Another big target push was made and in April it was found that the posters were up in 9 out of 17 clubs, so there was a slight increase as well as an additional public health campaign being added to the list.
The impact evaluation showed that of the 73 MSM surveyed, 54 (74%) reported seeing at least one campaign poster, so that goal was met. Of the 54 who reported seeing the poster, 44 (81%) could correctly recall the message, which was very pleasing. Of the 54 who had reported seeing the poster, 22 (41%) had reported talking to someone about the message. Of the 47 who had reported seeing the poster and who responded to the question, 22 (47%) reported attempting to change their behaviour or at least think about their behaviour as a result of the poster.
In summary, the campaign posters were attention grabbing but the reading level was too low and the font too small and the messages were too long and complex. The focus groups confirmed that while the posters grabbed attention, they needed to be much easier to read. They were not up in the majority of establishments but they were up after follow-up visits and the impact evaluation indicated their exposure and recall had been met, although the message transfer and behaviour change objectives were not met.
We concluded that we were going in the right direction but still needed to take a look at what the evaluation highlighted, what we were hearing about anecdotally, and what emerging trends had surfaced since the first year of the campaign. For the revision process, a series of meetings were held with club owners, community leaders and representatives of the population that we were reaching out to. There was a literature review and a search for emerging trends, and the evaluation results and the feedback were analysed.
The new campaign
The campaign goals and objectives remained the same with the exception of the emerging trends. The impact on occurrence or compliance was very important and had to be strictly adhered to in order to get the most effectiveness out of it, instead of stressing the potential for negative or fatal reactions when using recreational drugs in conjunction with HIV medication. There are many stories of people going out on a long binge and not taking their tablets with them.
The eight original posters were retained but a drug interaction section was developed. The campaign was taken to alternative venues to get the message out to people when they were not inside the club environment. The message was shortened and more direct and the font size was more visible. Other national and international organisations are being evaluated to see how they reach out to the gay community.
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