The third panel took a broader view of the strategies used for changing social norms by examining the roles of mass media campaigns, as well as other potential drivers of change, such as public policy, regulatory changes, and grassroots campaigns. Joanne Silberner introduced Phill Wilson, president and chief executive officer, Black AIDS Institute, who has done extensive work on global and national AIDS policies and has played a key planning role in international AIDS meetings. He talked about the value of accurate information in changing social norms. The second panelist was Robin Koval, president and chief executive officer, American Legacy Foundation,1 who spoke about the truth® campaign to prevent youth smoking (also discussed by Donna Vallone during the second workshop panel; see Chapter 3). Tony Foleno of the Ad Council, who had presented earlier (see Chapter 2), spoke again in this panel on changing social norms with respect to preventing bullying of teens who are gay and lesbian. Silberner also mentioned that Jay Winsten of the Harvard School of Public Health, who was on the agenda, was unable to participate in the workshop.
Wilson shared information about projects of the Black AIDS Institute and results of research that support its programming and messaging. He
1 Since the workshop, the name of the organization has changed from American Legacy Foundation to Truth Initiative to better align the organization’s identity with its primary program, the truth campaign.
showed a video that was part of the Greater Than AIDS campaign, a partnership between the Kaiser Family Foundation and the Black AIDS Institute. It was the first national HIV/AIDS campaign targeting black communities in the history of the HIV/AIDS epidemic and has now expanded to many different communities. The institute developed it with media partners up front rather than bringing the media in at the marketing phase. The video, titled “Creating Change with Our Voices,” showed people of different ages, genders, and races talking about their experiences as people who are lesbian, gay, bisexual, or transgender (LGBT). A main point was that much progress has been made in people coming out and establishing their civil rights, but that HIV is still in the closet, and people need to bring it out and talk about it.
Wilson explained that the root of the Greater Than AIDS campaign was an acknowledgment that everyone is part of a human, global family, and the only way for the human family to survive is for every person to do his or her part in addressing the HIV/AIDS epidemic. Therefore, this was a central message of the campaign. Wilson explained that the campaign started with black communities in the United States because data support that black communities are and have been the most impacted by the epidemic. Thus, to be successful in addressing HIV/AIDS in the United States, the campaign had to be successful in black communities. To counter much of the history of the epidemic built on the notion of death and dying, Wilson noted, another message of the original campaign was one of resilience. The initial message in black communities was that black people have been greater than all the challenges they have encountered in the past (e.g., the middle passage, slavery, reconstruction) and are also greater than HIV/AIDS. Other messages then focused on what people could do to contribute to ending the epidemic.
Wilson then turned to the institute’s program called When You Know Better, You Do Better, which centers on the state of HIV/AIDS science and treatment literacy in the workforce. He asserted that scientific breakthroughs will bring an end to the HIV/AIDS epidemic, at least in the United States. He explained that there are now better tools for surveillance, diagnosis, treatment, and biomedical prevention. For example, HIV transmission can be reduced by up to 96 percent through viral suppression, and acquisition of the virus can be reduced by helping people who are high risk and HIV-negative protect themselves though pre-exposure prophylaxis. Wilson cautioned, however, that no biomedical intervention will work if people do not believe in it or know how to use it effectively.
Wilson presented data showing indicators of progress toward ending the HIV/AIDS epidemic in the United States. He noted that roughly 86 percent of the 1.15 million Americans living with HIV know their HIV status. However, only 40 percent are engaged in care, only 37 percent are actually
prescribed the drugs that can save their lives and reduce their viral load, and only 30 percent are in optimal care or virally suppressed. Wilson suggested that this gap in treatment represents, in part, a disconnect between biomedical knowledge and behavior. He shared that he has been living with HIV for 35 years and that every night when he takes his medications, he notes that not a single one of those pills can enter his body without his assistance. Thus, he said, what the pills do is biomedical; what he does is behavioral. He stressed the importance of the institute’s work in changing behavior.
Wilson reported that as part of the When You Know Better, You Do Better Initiative, the Black AIDS Institute conducted a 3-year survey with close to 4,000 respondents from 48 states, the District of Columbia, and U.S. territories. Respondents were personnel in the nonmedical HIV/AIDS workforce. Wilson explained that the purpose of the study was to determine their level of basic knowledge, their knowledge of relevant terminology and treatment, and their clinical and biomedical knowledge, as well as their familiarity with and belief in the effectiveness of biomedical interventions.
Wilson reported that the study found that the average knowledge level among the respondents was very low. The median score was just 64 percent; only 4 percent of those surveyed would have scored an A, or 90 percent or better. With respect to specific components, they scored highest on basic knowledge and knowledge of terminology, with an average score of 73 percent. On knowledge of treatment, the percentages were in the mid-50s and on biomedical and clinical knowledge in the mid-40s. According to Wilson, these findings provided important feedback on the key elements that may drive ending the HIV/AIDS epidemic.
Wilson also pointed to some demographic differences. For example, blacks and Latinos and Hispanics scored lower than whites, by up to as much as 9 percentage points. And people who worked in the South scored lower than those working in other parts of the country.
With regard to familiarity and attitudes, Wilson continued, people who were familiar with biomedical interventions scored better on HIV/AIDS knowledge level relative to those who were not, and people who believed in the efficacy of biomedical interventions had a higher level of knowledge than those who did not. Wilson noted that fewer than 50 percent of respondents were familiar with biomedical interventions for HIV/AIDS. Only 37 percent were familiar with pre-exposure prophylaxis, 23 percent with topical microbicides, and 42 percent with treatment as prevention.
Wilson reported further that 30 to 45 percent of people working in the nonmedical HIV/AIDS workforce do not believe in the efficacy of biomedical interventions. He asserted that if the nonmedical workforce is unfamiliar with or does not understand interventions, chances of getting people to use them are not good.
Wilson concluded by offering suggestions for raising science and treatment literacy in the HIV/AIDS workforce. These included undertaking a major national initiative to increase HIV/AIDS science and treatment literacy, developing a clear set of core competencies for workers, establishing a nationwide certification program and a requirement for continuing education on HIV/AIDS science and treatment issues, and increasing the number of people who are living with HIV/AIDS who are in the HIV/AIDS workforce.
Koval began her presentation by explaining that she was going to expand on some of the points made earlier by Donna Vallone with regard to the American Legacy Foundation’s truth campaign (see Chapter 3). She discussed the critical need for social change campaigns to evolve continuously in accordance with the target population. She stated that the truth campaign has been considered the most successful youth tobacco prevention program ever mounted on a national scale, and a landmark in social change. The campaign, first launched in 2000, was created with funds resulting from the master settlement of the lawsuit between 46 states and the four large tobacco companies.
Koval explained that, instead of using scare tactics and negative judgments of smokers, the campaign’s messages were intended to give teens the unvarnished facts—the truth. She described the campaign’s starting point as trusting young people to make up their own minds, to do the right thing and influence their peers to do the same. She noted that the truth campaign was deliberately created to function as a brand rather than simply an advertising campaign. The brand actively connected with teens on their passion points—on music, art, action sports, and gaming—and in their own language. Koval explained further that efforts were made to be provocative and to generate strong emotional reactions, which, as the audience had heard from earlier presenters, could elicit high levels of recall and ultimately increase intentions not to smoke.
Koval noted that since its launch, the campaign has evolved significantly. Supplementing the mass media campaign in an experiential way, for example, large orange truth trucks go to amusement parks and various sporting events across the United States. Koval characterized this as a way to reach the grassroots level and deliver what some call a “one-to-one inoculation.”
As had been mentioned by Vallone, Koval reported that after the campaign’s first 2 years, results showed a 22 percent decline in youth smoking from 2000 to 2002, and that during the first 4 years of the campaign, 450,000 young people were prevented from smoking. She noted that the
teen smoking rate was 23 percent when the campaign started, and by 2010, this rate had declined to 12.8 percent. She observed that those results were amplified by other developments, such as enactment of clean air laws across the country and increases in the price of tobacco through taxation.
Koval went on to report that around 2011, the rate of smoking decline among young people started to stagnate as the result of a number of factors, such as cuts in truth spending brought on by the financial crisis in 2008 and major cuts in state spending across the country. Thus, she said, it was recognized that the campaign had to change in line with a new generation of youth. Changes in tobacco marketing and youth tobacco behavior and the digital social revolution were, she observed, changing the way young people interacted with messages. The campaign’s research was revealing that the rebellious, antibrand attitude reflected in the initial campaign was not appropriate for the postmillennial generation, whom Koval characterized as more cautious, more accepting, less desirous of rebelling, and less likely to see themselves as loners.
The focus of big tobacco was changing as well, Koval said, from younger teens to older teens and college-age youth who may be able to smoke legally. The other major shift, she noted, was that young people’s smoking behavior had evolved to become more intermittent and social, and if they smoked only at parties, they did not self-identify as smokers, a label that was associated with negative beliefs. “Party smoking” behavior was more socially acceptable to them and perceived as less harmful. She added that the digital social revolution has completely changed the way young people obtain and share information and formulate their attitudes and beliefs. Recent campaign results, she reported, showed that young people believe their social channels are literally their identities, their window to the world, and their source of news and beliefs. These channels, she observed, are also their source of influence. In the pre-Facebook era, the campaign could influence peer groups, but youth now may have hundreds or thousands of friends online who can be influenced.
Koval went on to explain that the challenge in 2014 was to reinvigorate the campaign by altering its brand to reflect all these changes. Beginning in 2015, she said, the campaign began leveraging the influence of social media. It shifted its target age group from 12-17 to 15-21, the older ages of smoking initiation. It also shifted from an individual focus on the most at-risk youth to a population focus, with the message that this will be the generation that ends smoking, which youth have the power to do now. Koval then showed a video illustrating this message that premiered during the MTV Video Music Awards.
Koval closed by sharing that a large evaluation program is in place involving a 10,000-person longitudinal cohort. She reported that early indicators from tracking data and an analysis of the cohort’s digital engage-
ment showed that the campaign appears to be gaining traction in terms of awareness, positive message receptivity, strong levels of social engagement, and cultural integration.
In his second presentation of the day, Foleno described a campaign to prevent gay and lesbian bullying, which he said did not draw major media attention but did have a large effect. He said he had chosen to talk about this campaign in particular because it concerns stigma and shines a spotlight on negative behaviors and attitudes, although focusing on the negative is often not advisable. In this case, the focus was on thoughtless behaviors among teens, including using antigay slurs and name calling. To show the scope of the problem, Foleno shared data from 2007 revealing that 9 in 10 LGBT teens had experienced some form of verbal or physical abuse, 7 in 10 had been verbally harassed, 2 in 10 had been physically harassed, and 1 in 10 had been physically assaulted (Harris Interactive, 2007).
Foleno described the campaign, which ran from 2008 through 2012, as aimed at reducing and preventing the use of homophobic slurs by straight teens throughout high school and educating teens that their homophobic slurs and behaviors, which they see as harmless, fun, or edgy, are in fact harmful. The objective of the campaign, he said, was also to drive teens first to a website on the issue and then to conversations online.
Foleno reminded the audience about a point he had made earlier—that many behaviors, including use of language, are habituated. For example, he said, use of the phrase “That’s so gay” to mean “That’s so stupid” may not be seen as harmful, but is in fact thoughtless, habituated, and entrenched and contributes to a larger climate of bullying and harassment. Thus, he explained, instead of targeting assaultive and more overt bullying behaviors, the campaign started with the everyday language that helps create this climate. He showed a broadcast spot used in the campaign in which two teens use the phrase “It’s so gay” to mean “That’s so stupid.” An adult who overhears them then says the same thing but substitutes the teens’ names in the phrase “It’s so gay” (“It’s so Emma and Julia”). The girls look surprised and perplexed when confronted.
Foleno added that the campaign used print media to make teens aware of stereotyping and how it feels when done to them, and other print media that included definitions of antigay slurs. He described a digital ad display that counted mentions of certain antigay slurs on Twitter. The counter was in real time, so one could see it clicking up every time one of those terms was used. The Ad Council partnered with various organizations to distribute it through channels including Fox Sports, AOL, Yelp, and TeenNick and worked with the National Basketball Association as well.
According to Foleno, the campaign’s evaluation framework includes metrics for assessing exposure (numbers for donated and earned media), awareness (recall of campaign), engagement (website and social media analytics), and impact (attitudes and behaviors). He described the effects of the campaign as measurably positive. In a national tracking survey among teens ages 13-17 (Ad Council, 2012), about 53 percent of respondents reported awareness of any aspect of the campaign over time, which he characterized as a home run in any campaign, either commercial or public service. With regard to changed attitudes and behaviors, self-reported survey data between 2008 and 2013 showed that fewer teens agreed that saying “That’s so gay” is no big deal; more said they never teased or called people names because they were gay or lesbian; and more said they never called someone “faggot” or “dyke.”
Foleno mentioned another antibullying campaign, It Gets Better, developed by a different organization. He described it as a terrific effort that included very similar sorts of messages.
Foleno concluded by saying that the Ad Council campaign was an example of a simple approach, a “don’t do” something message that sheds light on a larger issue of prejudice and discrimination, makes people think, and can be an effective gateway message. He showed a new Ad Council public service announcement (PSA), “Love Has No Labels,” which focuses on discrimination and stigma on a large scale across a variety of different identities and categories, but with a message of the power of love. He asserted that campaigns and their messages can stigmatize a bad behavior or celebrate a positive attitude, or can do both depending on their objectives.
The discussion session focused on the role of mass media and other strategies in influencing change in social norms. The discussant, Rebecca Palpant Shimkets, pointed out themes that had emerged from the presentations. She noted that defining the target audience appears to be essential and comes from knowing and following the data on populations and subgroups. She noted further that panelists had emphasized the importance of evaluating components of a campaign, modifying them, and evaluating them again. Evaluation, she said, can be a driver toward further funding and can compel the political will to move forward, and she highlighted the message that the willingness to change the course of a campaign is very important when indicated by evaluation results or changing social landscapes. She further noted the point that instead of trying to sell a campaign to partners, stakeholders, constituents, and policy makers, it is important to bring them into the development phase of a project; this is especially the case for media
partners. Finally, she said, the power of positive messaging appeared to be part of the success of the campaigns presented.
Subsequent topics of discussion ranged widely, covering the “Love Has No Labels” PSA, a follow-up question about the HIV/AIDS workforce survey, the issue of modeling problem behavior, framing of mental illness as a biological condition, the issue of complacency, and lessons about evaluation.
“Love Has No Labels”
Bernice Pescosolido started the discussion with a question for Foleno regarding the PSA “Love Has No Labels.” The video shows various groups of people embracing behind an x-ray screen, who then emerge from behind the screen. For each group, an inset on the screen scrolls with the words, “Love has no gender, . . . or age, . . . or race, . . . or religion, . . . or disability.” Pescosolido asked Foleno whether the Ad Council thought the video might not play well in different regions of the country. Foleno replied that the ideas behind the video had been pretested in the deep South, the Midwest, and urban areas with diverse groups of people. He characterized the video as relatively edgy in terms of challenging belief systems that people may not want to voice out loud. But regardless of their political persuasion, he argued, the message that love can overcome differences and that these differences may not matter so much resonated with many people, especially youth.
Another participant commented that, given all of the discussion about targets and knowing outcomes, the purpose of the video was not clear. Foleno explained that this PSA was a departure for the Ad Council because its clients usually are either nonprofit organizations or federal agencies. In this case, he said, the clients were Coca-Cola and Pepsi, Unilever and Procter and Gamble, and Nationwide plus some other insurance companies, all coming together for corporate social responsibility. The corporations, Foleno explained, wanted to demonstrate their commitment to the notion of diversity and inclusion. The Ad Council consulted with a consortium of civil rights and other organizations to find the best way to approach the task.
Foleno also remarked that the measurement effort was difficult. Initially, questions were included in the campaign’s tracker to gauge racism and homophobia in the United States generally. But Foleno explained that those issues were too large scale to be used as an outcome, so posts and shares were analyzed, and the key measure became spreading the word digitally.
Related to this topic, Palpant Shimkets commented that in “Love Has No Labels” and many other PSA campaigns on bias and diversity (e.g., the MTV bias campaign “You Can’t Call Me a ___”), mental illness in general and specific diagnoses are omitted. She asked whether this omission reflects
something about mental illness that makes it difficult to portray, or whether there is concern that including mental illness could stigmatize the rest of the campaign. Foleno replied that there could be some unconscious stigma attached to portraying mental illness within these campaigns, but that mental illness in general and specific conditions are not easily shown in such a video in the same way as sudden cardiac arrest.
Follow-up Question about the HIV/AIDS Workforce Survey
David Wegman asked Wilson about the people who were surveyed as part of the 3-year study of personnel in the nonmedical HIV/AIDS workforce. Wilson replied that there were more than 3,500 respondents who represented the spectrum of workers in HIV/AIDS (e.g., case managers, social workers, outreach workers, prevention workers), except those who actually prescribe. Doctors, nurses, nurse practitioners, and physician assistants were excluded for two reasons. He noted that, from a credibility point of view, a survey of the latter professionals would usually be conducted by a medical entity; moreover, some work had already been conducted on the level of knowledge among these personnel. Wilson explained further that the respondents came from large and small organizations, health departments, AIDS service organizations, and other community-based organizations. He said the survey was conducted in several ways: data were collected at a national conference, the U.S. Conference on AIDS; there was a national, state-by-state rollout in which teams of people went around the country to conduct the survey; and the survey was computer-based and available online. In addition, a Spanish augmentation ensured that Spanish speakers were oversampled.
Modeling of Problem Behavior
Joe Cappella asked Foleno about the counter on the website of the Ad Council’s campaign to prevent bullying of gay and lesbian teens, which provided a continuing update of the number of times antigay slurs occurred in social media, with the goal of getting the counter down to zero. Cappella suggested that goal could be problematic in light of the example presented earlier about the national youth antidrug media campaign, which had such high levels of saturation that it produced the meta-message, “A lot of kids are using drugs. Therefore, why am I not using drugs?” Cappella went on to say that, to point out a problem and create awareness, such campaigns often show examples of bad behavior that the audience is encouraged to avoid, but in showing those examples, the campaign is modeling the behavior. Foleno responded that there is always a danger of overusing such a method, as well as the potential to imply that hate speech is prevalent. In
this case, it was decided that use of this method would not interfere with the intended campaign message.
Koval addressed the issue of modeling behavior. Those involved in the truth campaign had many debates about the possibility that when a person is shown smoking, he or she becomes an unpaid spokesperson for big tobacco. By showing pictures of celebrities smoking, she asked, was the behavior being modeled? She pointed out that pretesting showed this not to be the case.
Koval also said that one of the major issues is portrayals of smoking in movies and on television. She noted that the good news about the popular television show “Mad Men,” in which smoking was prevalent, is that it was not watched by a lot of young people, so it did not set the campaign back. But, she suggested, it probably did influence adult smokers who were reinforced by it. She also shared that the campaign had learned that week that in addition to Disney Studios, Pixar, Marvel, and Lucasfilm would no longer be including any portrayals of tobacco use, other than historical, in any of their PG13-rated movies.
Framing Mental Illness as a Biological Condition
A virtual workshop participant asked about the effectiveness of framing mental illness as a biological condition to help reduce stigma. Wilson commented that in the HIV/AIDS space, knowledge that mental illness is a medical disease helps in delivering the message that there is something one can do about it, as well as in addressing the stigma issue. Unpacking the negative judgments associated with HIV/AIDS, he said, has been critically important in the evolution of the Black AIDS Institute’s campaigns. Foleno added that there is more debate as to whether substance abuse is a disease or a personal responsibility and the extent to which culture is involved.
Pescosolido confirmed that her research has shown that Americans do understand the biological basis of mental illness and that there is more negativity about substance abuse problems. Drug dependence is perceived more negatively than schizophrenia. However, there has been a backlash effect for the genetic explanation because if mental illness can be genetically passed down to future generations, people may be less accepting of those with mental illness marrying into their families.
The Issue of Complacency
Erin Board from Auburn, Washington, asked about the issue of complacency that may arise when campaigns are successful to the extent that people do not seek treatment. Wilson replied that in the current generation of the Greater Than AIDS campaign, the focus is in large part on addressing
the complacency that exists, particularly among gay and bisexual men. The greaterthan.org website includes first-person accounts that address awareness and what people can do.
Complacency is also a large issue in the truth campaign, according to Koval. In reworking the campaign, an effort is being made to counter this issue and give people a goal that is consistent with the state of smoking in the country today. Among youth, she noted, cigarette smoking rates are very low, at 8 percent, but the goal, she said, should be eradication.
Foleno added that the idea of complacency arises not only for these issues but for almost all of the Ad Council’s work. He suggested that when dealing with this issue, the best strategy is to outline the barriers to action, whether language, resources, or lack of knowledge. He added that it is difficult to identify the benefits and opportunities that would spark people out of complacency.
Lessons About Evaluation
David Wegman asked the panelists whether they had lessons learned about evaluating their campaigns that would inform new campaigns starting out. Wilson suggested that one of the advantages the institute had was an understanding of the importance of evaluation from the beginning. In addition, the institute’s partnership with the Kaiser Family Foundation emphasized research and evaluation. Specific indicators included the extent to which the campaign was being taken up, the extent of people’s awareness, and the extent of actual behavior change through testing and linkages to care.
Vallone said the 15-year-old truth campaign has yielded both long-term lessons learned and specific data obtained with the real-time continuous monitoring tracker. She directed the audience to a National Cancer Institute monograph looking at the role of media in reducing tobacco use, which synthesizes all the evidence over 25 years on how both pro- and antismoking messages have been used to increase as well as decrease smoking behavior. If evaluations are rigorous enough, she asserted, they should provide long-term lessons learned and up-to-date, execution-related information.
Foleno agreed with the other panelists and added that he counsels start-up projects to consider campaigns that are particularly inspiring, instructive, and connected to their issue and determine which of their general principles can yield a strategy that is suited to their issue and audience. He added that the antismoking literature is probably the best in this regard because this is the most well-researched area in public health communications. He said the field is lacking meta-analyses, but Cappella has added to that evidence base.
This page intentionally left blank.