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[Announcer] This podcast is presented by the Centers for Disease Control and Prevention. CDC – safer, healthier people.

[Leslie Snyder] Thank you all for coming. I know it’s very difficult choices about which session to attend and I personally wanted to be at four others in addition to this one, but I have no choice and I appreciate that you guys did have a choice and thank you for choosing this one and I think you’ll be really glad because we have some very interesting presentations this morning.

The goal of this session is to present and talk about and discuss and dissect some cutting edge approaches to social marketing and health communication. The speakers will be focusing on the important lessons from their work, including things about the campaign content, like messages, channels, theories, and also about the management of the campaign; their resources, the array of partners, expertise, partner relations, partner choices, and as the title says, we’re hoping that you’ll learn some lessons that you’ll want to try at home.

I’d also like to thank Shelly Spothe for organizing this session. There’s a lot of experience among the presenters, but also among the audience today and I’m looking forward to each talk and to the discussion at the end. So I’ve asked each speaker to talk for fifteen minutes and then we’ll have up to five minutes for clarification and some initial discussion right after each speaker, before we go on to the next speaker. And that hopefully, will leave us enough time at the end that we can really get some good discussion going.

Our first speaker is Melissa Krauss Taylor and she’s worked in health communication and social marketing for over fifteen years. She’s currently a Senior Vice President and heads Porter Novelli’s Atlanta’s Strategic Planning and Research Department where she consults on a variety of public and private sector campaigns, including CDC’s Learn the Signs, Act Early and HIV testing campaigns and CDC and Lysol Ounce of Prevention partnership. Melissa also teaches social marketing at Emory University’s Rollins School of Public Health.

[Melissa Taylor] Thank you so much; this is really exciting. Standing room only. I wasn’t sure that a topic on theory would generate, you know, such a crowd. You’re probably here to hear from Tina and Nancy, so I’m glad they put me first because you can’t sneak out before listening to mine.

That sort of leads me to my first point here that theory – it’s really not a dirty word. You know, I kind of tend to lean a little bit more towards the academic side. Some of my colleagues remind me of that quite frequently. Melissa not all of us really care to live in the Ivory Tower. Bring it back down to reality and no, I just don’t try to use theories so that I can use big impressive words and try to make myself sound smarter than everyone else, but what I find is that theory is very helpful in just understanding why it is we behave in the way that we do. And it’s a great lens or framework in understanding and really thinking through some of the communication and health marketing challenges that we’re faced with and really as we’re starting to think through what types of strategies and approaches should we use. There are so many different tools in our toolbox that we can select from. How do we know what is most appropriate? What’s the rationale for selecting one approach over another? And often when we get to sort of the what comes at kind of the end of the campaign; if we’ve got enough energy to sustain and we’re looking at evaluation and trying to figure out have we actually made a difference, having a theoretical framework also really helps to frame out what it is we expect to see happen at the end and what it is we should be measuring. So, it’s really not a dirty word and I believe that theory can be a great bridge between sort of the Ivory Tower sort of academic setting where we’re studying why do people act the way they do and moving into the applied settings that all of us spend so much of our time working with and trying to actually make a difference. So I want to demonstrate this using two different campaigns. The first is the CDC’s HIV Take Charge, Take the Test campaign and I have to make sure that I explain this accurately because we have the Campaign Manager here, Shelly Spathe, the brains behind this campaign and Jamie Fraize, who’s not here today is also a key developer in this campaign. Both of whom are with CDC. And I could spend probably the next three hours telling you all about this wonderful campaign. I’m going to try to keep this into two minutes so that I can just give you some of the highlights in terms of how we applied a behavioral change framework approach or theoretical approach in the development of this campaign and how using theory helped us really identify which strategies would be most appropriate. So I want to start with, which is really where all of us should start is, understanding our target audience and the challenge at hand. Our campaign was focused on increasing HIV testing among young, African American women. This is an audience whom we quickly learned did not really themselves at need of getting tested. Some may have thought they already were tested when they were pregnant or during just an annual exam. They didn’t really know for certain if they were and really it’s those sort of promiscuous people, the other people out there. Not me. I’m in a relationship. I’m a responsible person. I’m not at risk of HIV. We also found very quickly that this group did not have a strong social support system. If they were found out to be HIV positive they would quickly be stigmatized and shunned by their community. At least that was there perception and what they had seen sort of in others that they knew who had tested positive. Never mind the fact that going to get a test meant walking through the door that said HIV testing, or STD clinic. Well you know only those girls, kinds of girls walk through that door. So all kinds of barriers just in a sort of social, cultural context that would keep them. Now one area where we did start to see, that we could get them thinking a little bit was around the fact that you know I can’t always know what my partner’s doing. I know what I’m doing. I know that I’m being responsible and I’m being faithful to my partner. I’m not with my partner twenty-four seven. That may cause a little bit, it was an opening to get people to think about, potentially I guess I could be at risk for HIV. Knowing the sort of mindset of our particular target audience and some of the challenges because you see they knew about HIV. They knew about HIV testing. Where to go, that they could get it for free. In sort of a general sense they knew that there were treatments out there, although really those treatments are typically for the wealthy and the famous, not me. So they knew all of that, but they weren’t going to get tested because there was such a big barrier between themselves and how they perceived themselves and someone who would walk the door of an HIV clinic. So, what did that tell us? Well knowing that information, we looked at some of the different behavior change theories at our disposal and it really, I have to say this is as much an art as it is a science. It’s really sort of looking through and seeing what can explain sort of where these women are in their thinking and what may keep them from getting tested and what actually can we help to influence them getting tested? And one of the first important areas is really understanding the cultural norms and this whole social ecological framework, which is really what this first box represents. The whole, at an individual level, that one-on-one communication, the community level, organizations, all of those different levels of and contacts within which these women lived and all of those messaging that either reinforced or reinforced negative stereotypes and misperceptions or potentially could be used to help share correct information. That was a key component and you’ll see how that’s played out in our strategy. Well we then looked at sort of this next set and I apologize, I should have blown this up a little bit bigger, but the next theory that we borrowed from was a theory of planned behavior. If you look at sort of, you’ve got this individual whose had unprotected sex, sort of entering into this. Well theory of planned behavior says that your beliefs about the behavior, thus resulting in your attitudes towards the behavior. Your beliefs about what others think and your beliefs about your ability to engage in the behavior all are going to impact whether or not you intend to do the behavior. Well this was pretty interesting for us to think through because again, we knew that in general there was a positive perception, I mean HIV tests work. That wasn’t really sort of debatable. That was believed by our audience. There was some disagreement or some disbelief that treatment might actually be possible and helpful to this audience, but overall the beliefs around HIV testing were relatively positive, but when you looked at that and this is why this box is bigger, hint, hint. When you looked at the normative beliefs around who gets tested, why you would get tested and the support if you were found to be HIV positive really was playing a big role and again a control beliefs these women knew where to get tested and it wasn’t so much that they didn’t think they could get tested, but it was again, how much do they want to put themselves at risk of being perceived differently then how they viewed themselves by getting tested again, at an HIV clinic. So, we looked at those constructs through the filter of our audience. We also just because we like to make this fun added in a third theoretical set of constructs; the health belief model, it should look familiar. Now let me go back to a minute with the theory of plan behavior. This really helped us cement some of the strategic direction for our campaign and the fact that community and norms was going to play a big role in this campaign. The health belief model helped to identify what were some of the different messaging. So if theory of planned behavior was informing how we were going to approach this campaign, health belief model helped informed what it is we were going to say. What’s important in our messaging. And you see we sort of linked it up because these theories work very nicely together. Our attitudes towards the behavior of this behavioral beliefs really sort of synced up with the perceived severity, susceptibility and perceived benefits around HIV testing. The perceived barriers in this particular instance again, really related to cultural norms and thoughts about again sort of how I would be viewed by those that I admire and those who are important to me. How would they think about me being tested? And the cues to action in health belief model tied nicely to again this thought around, I know how I can get tested, but what’s really going to prompt me to do that? So again, this helped to inform us, inform our thinking in terms of what it is we needed to say. All of that then leading to the intention to get tested, leading to getting tested, importantly getting the results, which was a key element of this campaign. One of the things that we did is to make sure that the cities that we worked in had a link into counseling and prevention and treatment services so that we did not leave anyone sort of hanging. I can’t, I don’t have time unfortunately to go into the entire campaign, but I do want to talk with you about some of the results and again, the real strategic development here, if you couldn’t guess is that this was very community driven, which meant that we in picking the two cities, Cleveland and Philadelphia where we worked we made an extended effort to have a local presence there; hiring city coordinators to build relationships and really create a sustainable long lasting campaign. Worked with local partners. You’ll see that over a hundred partners were trained. This not only helped to engage them in this campaign, but also establish skills and capacity so that beyond this particular campaign they can continue to make an impact in their careers. Not only local presence getting very non-traditional partners and reaching out to the colleges and universities. Reaching out to the beauty salons. Reaching out to the churches. All kinds of ways that our audience, where they went to live, work, and play and the people that they responded to. The picture of the woman here is one of the spokespeople in the campaign. Again we wanted to make sure that these were women who in fact have gone through this process, found out that they were HIV positive and could be positive role models to the women. If we went in talking as CDC, we never would have been listened to. It ties in very nicely to what Walker Smith was talking about this morning. In fact the logo you saw at the beginning of this section of the presentation is the whole campaign was around Take Charge, Take the Test. We wanted to empower women locally to do this. Another key element of this was that instead of asking women to do all of the work and go to this very sort of stigmatizing HIV clinic to get tested, we brought testing to them and hosted a number of different local events. Bringing in musicians, doing poetry slams, all kinds of on campus testing making it very fun and relevant to the women and giving them an opportunity in a very sort of de-stigmatized, a very sort of acceptable setting to get tested. There have been over sixteen hundred attendees at these events that we’ve held in the past nine to twelve months and what’s really important is that we’re seeing that women are getting tested and as a result, which was a really important focus of this campaign. It’s not only that these women are getting tested, but that women who have HIV are finding out that they’re positive, so that they can in fact take action and so we’re starting to see more of that. I could go on for hours talking about a lot of the exciting elements of this campaign. I’m going to direct you to Shelly for all those questions after the presentation. So let me take a moment to switch to another campaign. Another CDC campaign. Learn the Signs After Early campaign, which is an early childhood development campaign, which in shorthand we call our Autism Awareness Campaign. But you know if you look through any of the materials you won’t see the word autism displayed prominently in any of the information and that was very intentional. I’m going to talk with you about how, again, our audience perspective and application of a theoretical framework helped us get to that decision. So again starting with the audience. Audience, parents of young children, usually mom is sort of the predominant health information seeker, health decision maker. You know we found over and over again that moms and even Pediatrician’s naturally sort of gravitate to the physical growth and development milestones, right? The child rolling over, sitting up, even some of the first words, first tooth coming in. Those are all very natural sort of milestones that parents tend to talk about, compare with one another. But when it gets beyond that there really wasn’t an awareness of what they should be looking for. Often times if they did express a concern about maybe a delay in their child’s development a Pediatrician would be very dismissive of it. And if someone did happen to mention the word autism a parent shut down. That was too scary. Autism, that’s Rainman. That is a very extreme developmental delay of which there is no hope and I can’t think about that. So what do we do? Well, one of the first things we realized in looking at where our audience was is they really fell within this pre-contemplation. All of you I’m sure are familiar with stages of change. There was a lot of low awareness about the fact even that they need to be looking for cognitive, social, emotional milestones. Yes, they knew they needed to be looking for childhood development, but mostly around physical development. So, they weren’t even aware that there were really signs they could be watching for in terms of developmental delay. And when we looked at their reactions to terms, very scary terms like autism we found that they really wanted to shut down. And this was confirmed by a number of research articles that look at the effectiveness of fear appeals at different stages along the stages of change continuum. What happens is when you’re at the pre-contemplation stage and you hear these sort of very fear arousing or fear inducing messages, it actually causes you to think that you’re less at risk and less susceptible. It can actually have you sort of completely the opposite effect of what you wanted. So what we ended up doing after testing a number of different approaches is really link back to a parent’s desire to be a good parent. A parent’s natural tendency to monitor their child’s development and to compare their child’s development; talking amongst their friends, sort of talking with their doctor about well what should I be watching for next. There’s an interesting whole approach in terms of cognitive dissonance and I’m out of time and I’m going to whiz through this that when you present somebody, when a person self identifies in one way and you give them information showing that their current behavior is contrary to that, their willing to make changes. So in a very non-threatening way when we were able to say to parents, we know that you care about your child’s development, but it’s time to look at this differently. It’s time to look at more; the full development. They are much more willing to engage with us to find out what that was all about and open up this whole conversation to learn about what potential signs they need to be looking at and we’re seeing results, positive results of that. We are getting parents to pay attention to this message. They’re talking to their physicians and our physician outreach is opening up that dialogue as well.

Thank you so much. This is really exciting. Standing room only. I wasn’t sure that a topic on theory would generate such a crowd. You’re probably here to hear from Tina and Nancy, so I’m glad they put me first because you can’t sneak out before listening to mine. That sort of leads me to my first point here that theory is really not a dirty word. I kind of tend to lean a little bit more towards the academic side. Some of my colleagues remind me of that quite frequently. Melissa not all of us really care to live in the Ivory Tower. Bring it back down to reality and no, I just don’t try to use theories so that I can use big impressive words and try to make myself sound smarter than everyone else, but what I find is that theory is very helpful in just understanding why it is we behave in the way that we do. And it’s a great lens or framework in understanding and really thinking through some of the communication and health marketing challenges that we’re faced with and really as we’re starting to think through what types of strategies and approaches should we use. There are so many different tools in our toolbox that we can select from. How do we know what is most appropriate? What’s the rationale for selecting one approach over another? And often when we get to sort of the what comes at kind of the end of the campaign; if we’ve got enough energy to sustain and we’re looking at evaluation and trying to figure out have we actually made a difference, having a theoretical framework also really helps to frame out what it is we expect to see happen at the end and what it is we should be measuring. So, it’s really not a dirty word and I believe that theory can be a great bridge between sort of the Ivory Tower sort of academic setting where we’re studying why do people act the way they do and moving into the applied settings that all of us spend so much of our time working with and trying to actually make a difference. So I want to demonstrate this using two different campaigns. The first is the CDC’s HIV Take Charge, Take the Test campaign and I have to make sure that I explain this accurately because we have the Campaign Manager here, Shelly Spathe, the brains behind this campaign and Jamie Fraize, who’s not here today is also a key developer in this campaign. Both of whom are with CDC. And I could spend probably the next three hours telling you all about this wonderful campaign. I’m going to try to keep this into two minutes so that I can just give you some of the highlights in terms of how we applied a behavioral change framework approach or theoretical approach in the development of this campaign and how using theory helped us really identify which strategies would be most appropriate. So I want to start with, which is really where all of us should start is, understanding our target audience and the challenge at hand. Our campaign was focused on increasing HIV testing among young, African American women. This is an audience whom we quickly learned did not really themselves at need of getting tested. Some may have thought they already were tested when they were pregnant or during just an annual exam. They didn’t really know for certain if they were and really it’s those sort of promiscuous people, the other people out there. Not me. I’m in a relationship. I’m a responsible person. I’m not at risk of HIV. We also found very quickly that this group did not have a strong social support system. If they were found out to be HIV positive they would quickly be stigmatized and shunned by their community. At least that was there perception and what they had seen sort of in others that they knew who had tested positive. Never mind the fact that going to get a test meant walking through the door that said HIV testing, or STD clinic. Well you know only those girls, kinds of girls walk through that door. So all kinds of barriers just in a sort of social, cultural context that would keep them. Now one area where we did start to see, that we could get them thinking a little bit was around the fact that you know I can’t always know what my partner’s doing. I know what I’m doing. I know that I’m being responsible and I’m being faithful to my partner. I’m not with my partner twenty-four seven. That may cause a little bit, it was an opening to get people to think about, potentially I guess I could be at risk for HIV. Knowing the sort of mindset of our particular target audience and some of the challenges because you see they knew about HIV. They knew about HIV testing. Where to go, that they could get it for free. In sort of a general sense they knew that there were treatments out there, although really those treatments are typically for the wealthy and the famous, not me. So they knew all of that, but they weren’t going to get tested because there was such a big barrier between themselves and how they perceived themselves and someone who would walk the door of an HIV clinic. So, what did that tell us? Well knowing that information, we looked at some of the different behavior change theories at our disposal and it really, I have to say this is as much an art as it is a science. It’s really sort of looking through and seeing what can explain sort of where these women are in their thinking and what may keep them from getting tested and what actually can we help to influence them getting tested? And one of the first important areas is really understanding the cultural norms and this whole social ecological framework, which is really what this first box represents. The whole, at an individual level, that one-on-one communication, the community level, organizations, all of those different levels of and contacts within which these women lived and all of those messaging that either reinforced or reinforced negative stereotypes and misperceptions or potentially could be used to help share correct information. That was a key component and you’ll see how that’s played out in our strategy. Well we then looked at sort of this next set and I apologize, I should have blown this up a little bit bigger, but the next theory that we borrowed from was a theory of planned behavior. If you look at sort of, you’ve got this individual whose had unprotected sex, sort of entering into this. Well theory of planned behavior says that your beliefs about the behavior, thus resulting in your attitudes towards the behavior. Your beliefs about what others think and your beliefs about your ability to engage in the behavior all are going to impact whether or not you intend to do the behavior. Well this was pretty interesting for us to think through because again, we knew that in general there was a positive perception, I mean HIV tests work. That wasn’t really sort of debatable. That was believed by our audience. There was some disagreement or some disbelief that treatment might actually be possible and helpful to this audience, but overall the beliefs around HIV testing were relatively positive, but when you looked at that and this is why this box is bigger, hint, hint. When you looked at the normative beliefs around who gets tested, why you would get tested and the support if you were found to be HIV positive really was playing a big role and again a control beliefs these women knew where to get tested and it wasn’t so much that they didn’t think they could get tested, but it was again, how much do they want to put themselves at risk of being perceived differently then how they viewed themselves by getting tested again, at an HIV clinic. So, we looked at those constructs through the filter of our audience. We also just because we like to make this fun added in a third theoretical set of constructs; the health belief model, it should look familiar. Now let me go back to a minute with the theory of plan behavior. This really helped us cement some of the strategic direction for our campaign and the fact that community and norms was going to play a big role in this campaign. The health belief model helped to identify what were some of the different messaging. So if theory of planned behavior was informing how we were going to approach this campaign, health belief model helped informed what it is we were going to say. What’s important in our messaging. And you see we sort of linked it up because these theories work very nicely together. Our attitudes towards the behavior of this behavioral beliefs really sort of synced up with the perceived severity, susceptibility and perceived benefits around HIV testing. The perceived barriers in this particular instance again, really related to cultural norms and thoughts about again sort of how I would be viewed by those that I admire and those who are important to me. How would they think about me being tested? And the cues to action in health belief model tied nicely to again this thought around, I know how I can get tested, but what’s really going to prompt me to do that? So again, this helped to inform us, inform our thinking in terms of what it is we needed to say. All of that then leading to the intention to get tested, leading to getting tested, importantly getting the results, which was a key element of this campaign. One of the things that we did is to make sure that the cities that we worked in had a link into counseling and prevention and treatment services so that we did not leave anyone sort of hanging. I can’t, I don’t have time unfortunately to go into the entire campaign, but I do want to talk with you about some of the results and again, the real strategic development here, if you couldn’t guess is that this was very community driven, which meant that we in picking the two cities, Cleveland and Philadelphia where we worked we made an extended effort to have a local presence there; hiring city coordinators to build relationships and really create a sustainable long lasting campaign. Worked with local partners. You’ll see that over a hundred partners were trained. This not only helped to engage them in this campaign, but also establish skills and capacity so that beyond this particular campaign they can continue to make an impact in their careers. Not only local presence getting very non-traditional partners and reaching out to the colleges and universities. Reaching out to the beauty salons. Reaching out to the churches. All kinds of ways that our audience, where they went to live, work, and play and the people that they responded to. The picture of the woman here is one of the spokespeople in the campaign. Again we wanted to make sure that these were women who in fact have gone through this process, found out that they were HIV positive and could be positive role models to the women. If we went in talking as CDC, we never would have been listened to. It ties in very nicely to what Walker Smith was talking about this morning. In fact the logo you saw at the beginning of this section of the presentation is the whole campaign was around Take Charge, Take the Test. We wanted to empower women locally to do this. Another key element of this was that instead of asking women to do all of the work and go to this very sort of stigmatizing HIV clinic to get tested, we brought testing to them and hosted a number of different local events. Bringing in musicians, doing poetry slams, all kinds of on campus testing making it very fun and relevant to the women and giving them an opportunity in a very sort of de-stigmatized, a very sort of acceptable setting to get tested. There have been over sixteen hundred attendees at these events that we’ve held in the past nine to twelve months and what’s really important is that we’re seeing that women are getting tested and as a result, which was a really important focus of this campaign. It’s not only that these women are getting tested, but that women who have HIV are finding out that they’re positive, so that they can in fact take action and so we’re starting to see more of that. I could go on for hours talking about a lot of the exciting elements of this campaign. I’m going to direct you to Shelly for all those questions after the presentation. So let me take a moment to switch to another campaign. Another CDC campaign. Learn the Signs After Early campaign, which is an early childhood development campaign, which in shorthand we call our Autism Awareness Campaign. But you know if you look through any of the materials you won’t see the word autism displayed prominently in any of the information and that was very intentional. I’m going to talk with you about how, again, our audience perspective and application of a theoretical framework helped us get to that decision. So again starting with the audience. Audience, parents of young children, usually mom is sort of the predominant health information seeker, health decision maker. You know we found over and over again that moms and even Pediatrician’s naturally sort of gravitate to the physical growth and development milestones, right? The child rolling over, sitting up, even some of the first words, first tooth coming in. Those are all very natural sort of milestones that parents tend to talk about, compare with one another. But when it gets beyond that there really wasn’t an awareness of what they should be looking for. Often times if they did express a concern about maybe a delay in their child’s development a Pediatrician would be very dismissive of it. And if someone did happen to mention the word autism a parent shut down. That was too scary. Autism, that’s Rainman. That is a very extreme developmental delay of which there is no hope and I can’t think about that. So what do we do? Well, one of the first things we realized in looking at where our audience was is they really fell within this pre-contemplation. All of you I’m sure are familiar with stages of change. There was a lot of low awareness about the fact even that they need to be looking for cognitive, social, emotional milestones. Yes, they knew they needed to be looking for childhood development, but mostly around physical development. So, they weren’t even aware that there were really signs they could be watching for in terms of developmental delay. And when we looked at their reactions to terms, very scary terms like autism we found that they really wanted to shut down. And this was confirmed by a number of research articles that look at the effectiveness of fear appeals at different stages along the stages of change continuum. What happens is when you’re at the pre-contemplation stage and you hear these sort of very fear arousing or fear inducing messages, it actually causes you to think that you’re less at risk and less susceptible. It can actually have you sort of completely the opposite effect of what you wanted. So what we ended up doing after testing a number of different approaches is really link back to a parent’s desire to be a good parent. A parent’s natural tendency to monitor their child’s development and to compare their child’s development; talking amongst their friends, sort of talking with their doctor about well what should I be watching for next. There’s an interesting whole approach in terms of cognitive dissonance and I’m out of time and I’m going to whiz through this that when you present somebody, when a person self identifies in one way and you give them information showing that their current behavior is contrary to that, their willing to make changes. So in a very non-threatening way when we were able to say to parents, we know that you care about your child’s development, but it’s time to look at this differently. It’s time to look at more; the full development. They are much more willing to engage with us to find out what that was all about and open up this whole conversation to learn about what potential signs they need to be looking at and we’re seeing results, positive results of that. We are getting parents to pay attention to this message. They’re talking to their physicians and our physician outreach is opening up that dialogue as well.

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