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Am J Public Health. 2008 February; 98(2): 337–343.
PMCID: PMC2376895

Short-Term Impact Evaluation of a Social Marketing Campaign to Prevent Syphilis Among Men Who Have Sex With Men

Abstract

Objectives. We carried out an independent short-term impact evaluation of a social marketing campaign designed to reduce syphilis infections among men who have sex with men in south Florida in 2004.

Methods. Venue-based surveys were conducted shortly after the campaign began and 6 months later to assess changes in exposure to campaign materials, awareness, knowledge about syphilis, perceptions of risk, sexual behavior, clinic visits, and testing and treatment for syphilis among participants.

Results. Exposure to social marketing campaign materials increased from 18.0% at baseline to 36.5% at follow-up (P< .001). Awareness of syphilis and perceptions of risk increased among Broward County residents but not among Miami–Dade County residents. Risky sexual practices and patterns of recreational drug use did not change. No significant increases in knowledge, clinic visits, or testing or treatment for syphilis among participants were detected over the 6-month study period.

Conclusions. None of the campaign objectives were fully met. The interventions were insufficient to produce a significant impact among men who have sex with men in south Florida.

By the end of the 20th century, reported cases of syphilis in the United States had reached an all-time low. Most of the new cases were reported among impoverished African American heterosexual adults living in 28 counties, located primarily in the South. Some officials believed that with an intensified effort, the few remaining cases of infectious syphilis might be identified and brought to treatment. In June 1999, the Centers for Disease Control and Prevention (CDC) announced the National Plan to Eliminate Syphilis from the United States.1

Shortly after the national plan was introduced, reported cases of syphilis in the United States began to rise. In San Francisco, for example, the number of cases of early syphilis increased from 41 in 1998 to 495 in 2002, and the proportion of cases reported among men who have sex with men (MSM) increased from 22% to 88%.2 Investigation of the outbreak in San Francisco revealed that many MSM were meeting their sexual partners through Internet connections and that a disproportionate number of those who had acquired syphilis were already infected with HIV.

Based on observations made in San Francisco and elsewhere,39 the CDC initiated an 8-city intervention project in fiscal year 2004.10 Two of the 8 cities, Fort Lauderdale and Miami, Fla, were experiencing a recrudescence of infectious syphilis among MSM but had little information available about the sexual behaviors, patterns of recreational drug use, or other characteristics of those who were being exposed to and were becoming infected with syphilis.11 Therefore, the State of Florida Department of Health, Bureau of STD Prevention and Control requested that baseline and follow-up surveys of MSM be conducted in Fort Lauderdale and Miami to describe the target populations of MSM, guide the development of a social marketing campaign, and evaluate the campaign’s effectiveness. We conducted an evaluation of the short-term impact of the campaign with adult MSM recruited from diverse venues in Fort Lauderdale (Broward County) and Miami (Miami–Dade County) in 2004.

METHODS

An untreated control group design with separate pre- and posttest samples was selected as the best available option.12 Cross-sectional surveys with adult MSM in Broward and Miami–Dade counties were conducted in winter and again in fall 2004 to describe at-risk populations and assess baseline and follow-up measures of exposure to campaign messages and materials, awareness of the current syphilis outbreak, knowledge about syphilis, perceptions of risk, sexual and drug-using behaviors, clinic visits, tests for syphilis, and treatment in the past year. An anonymous, self-administered questionnaire was completed by eligible respondents. Responses of Florida residents were compared with responses of MSM who lived out of state, and responses of Broward residents were compared with responses of Miami–Dade residents.

Recruitment and Data Collection

Diverse samples of MSM in central locations of Broward and Miami–Dade counties on 3 consecutive weekends from February 28 to March 14 and all weekends in October 2004 were sought. Five venues in Fort Lauderdale (a nightclub, a bar, a public beach, a gay pride event, and the Gay and Lesbian Community Center Swap Shop) and 5 in Miami–Dade County (2 nightclubs, a bar, a public beach, and the Miami Beach Antiques and Collectibles Market) were selected after consulting with community members and local ethnographers.

Men found in these locations were approached by a trained staff member who introduced himself or herself and the health survey and asked whether they might be interested in participating. Those who indicated an interest were screened for eligibility. Each respondent had to be 18 years or older and have at least 1 lifetime sexual experience (oral or anal sexual intercourse, with ejaculation) with a man to be eligible.

The 12-page, 20-item questionnaire used to gather baseline and follow-up data in south Florida was modeled after a 13-page, 49-item questionnaire used 2 years earlier to assess the impact of the Stop the Sores13 and Healthy Penis14,15 campaigns among gay and bisexual men in California.13,14 The data collection instrument used in south Florida had sections that corresponded with the California instrument, but it was shortened and modified to be consistent with questionnaire items used previously in south Florida.16,17 In addition, the questionnaire for adult MSM in south Florida was translated into Spanish, back-translated into English, and approved for administration in either English or Spanish.

Eligible MSM who agreed to participate were given a consent and reimbursement form to check off, a questionnaire, a clipboard, and a pencil. The staff member first collected the consent form and then, after the respondent completed it, the questionnaire. After checking that all pages had been filled in and asking respondents whether they had answered each question to the best of their ability, the staff member gave $10.00 to those who wished to accept it. Graduate students enrolled in public health courses collected, coded, cleaned (i.e. checked to confirm that information provided by the respondents was coded correctly and any discrepancies in responses were resolved before data analysis began), and verified survey data before analysis. All received sensitivity training for interactions with stigmatized populations and specialized training in the protection of human research participants, fieldwork methods for survey research, and quantitative data analysis procedures used with SPSS version 13.0 (SPSS Inc, Chicago, Ill). Each was required to provide a certificate indicating that she or he had completed National Institutes of Health requirements before entering the field.

Interventions

The social marketing campaign was designed, developed, and implemented by the South Florida Syphilis Coalition (SFSC). Two staff members working for the United Foundation for AIDS created and produced campaign materials, with the cooperation, support, and approval of State of Florida Department of Health and local health officials. The campaign was based on social marketing theory,1822 but several important principles of the theory were compromised in the interest of addressing the apparent problem quickly.

Instead of calling together focus groups with representative samples of MSM, for example, local health department staff asked patients seeking STD services at local clinics to review and respond to rough drafts of materials before they were printed and distributed. Examples of the earliest available materials are displayed in Figure 1 [triangle]. Altogether, 800 posters and 173000 palm cards were distributed in bars, clubs, and elsewhere; 119 advertisements were placed in local publications; 6 billboards were put up; syphilis alert banners appeared on 3 Web sites; and 3 different public service announcements were created and scheduled to be broadcast 1770 times on radio or television.

FIGURE 1
Social marketing campaign materials distributed by the South Florida Syphilis Coalition (SFSC): 2003 and early 2004.

The United Foundation for AIDS began rolling out its campaign materials before baseline survey materials and procedures were approved by the institutional review board. The first set of posters, palm cards, and advertisements, featuring Adora (a popular drag queen), was introduced at the White Party (a major AIDS fund-raising event) held over Thanksgiving weekend, 2003. Other materials were developed and released at a rate of approximately 1 per month from January through October 2004. Thus, the campaign was under way when baseline data collection began in late February 2004.

Variables

The major independent variables analyzed for this article were date of data collection (baseline [winter] or follow-up [fall]), state of residence (Florida or elsewhere), and county of residence in south Florida (Broward or Miami–Dade). Major intervening and dependent variables included measures of exposure to specific materials created for the campaign and other information about syphilis, a 12-question test of knowledge about syphilis, recreational drug use in the past year, risky sexual practices related to syphilis infection in the past year and in the past month, visits to doctors’ offices and local clinics, tests for syphilis, and treatment for syphilis in the past year.

The test of knowledge (answers were true, false, or unsure) was developed to measure how much of the information contained in the CDC’s fact sheet about syphilis and MSM23 was known by respondents. The null hypothesis tested in the nonrandomized evaluation was that the campaign had no statistically significant effects on any of the dependent variables of interest to the SFSC when evaluated by the Pearson χ2 test.

RESULTS

The median age of study participants was 37 years (range = 18–73) at baseline and 36 years (range = 18–80) at follow-up; 56.3% of 406 MSM at baseline (including 6 who did not provide their age) and 54.6% of 445 at follow-up (including 4 who did not provide their age) were 35 years or older (P = .64). Most men (55.7% at baseline and 51.2% at follow-up) had received a college degree (P = .19) and were working full time (60.6% at baseline and 54.3% at follow-up; P = .06). The majority of respondents reported being members of racial or ethnic minority populations (29.1% were White, Hispanic; 18.8% were Black or African American; 5.4% were Black, Hispanic; 1.3% were Asian; 0.2% were Native American or Pacific Islander; and 2.1% were other); 45.9% at baseline and 40.3% at follow-up considered themselves to be “White, non-Hispanic” (P = .81). Except for the lower proportion of out-of-state residents who were classified as White, non-Hispanic, characteristics of men enrolled at follow-up were comparable with those of men enrolled at baseline (Table 1 [triangle]).

TABLE 1
Sample Baseline and Follow-Up Characteristics of Men Who Have Sex With Men Living In or Visiting South Florida: 2004

Overall, 16.3% at baseline and 19.8% at follow-up reported testing positive for HIV (P = .19). Altogether, 297 survey participants lived in Miami–Dade and 326 lived in Broward County. In Broward, the proportion of respondents who said they were infected with HIV increased from 21.6% at baseline to 31.6% at follow-up (P = .04). Although similar venues were used in winter and fall, fewer (79.8% of 406) at baseline than at follow-up (91.9% of 445) said they were residents of Florida (P < .001).

Exposure, Awareness, Knowledge, and Perception of Risk

Reports of exposure to items developed for the social marketing campaign increased from 18.0% at baseline to 36.5% at follow-up (P < .001). Few out-of-state residents reported seeing any of the items at baseline or at follow-up (Table 2 [triangle]). For Adora campaign items, the increase in exposure among men living in Florida was from 20.2% to 30.0% (P = .002); for In the Dark, it was from 10.5% to 23.7% (P < .001); and for Hot Sex! campaign items, it was from 12.9% to 18.6% (P = .03).

TABLE 2
Impact of Social Marketing Campaign on Men Who Have Sex With Men Living In or Visiting South Florida: 2004

Florida residents were more likely at follow-up than at baseline to have heard something about syphilis on the radio or to have seen something on the Internet or on a billboard (P < .05). An increased awareness of syphilis through these 3 vehicles, newspapers, and television was entirely attributable to reports from residents of Broward County (Table 3 [triangle]). No increase in awareness through any of these media channels occurred among Miami–Dade residents or among respondents who lived outside of Florida.

TABLE 3
Impact of Social Marketing Campaign on a Sample of Men Who Have Sex With Men Living In Miami–Dade and Broward Counties, 2004

Information levels tended to be higher at baseline for Miami–Dade residents than for Broward residents. For example, 41.4% of Miami–Dade residents said they had seen something about syphilis on 3 or more media outlets at baseline and 43.6% at follow-up (Table 3 [triangle]). Among Broward residents, the increase from 29.7% at baseline to 44.6% at follow-up was statistically significant (P = .006).

Although exposure to campaign materials and awareness of syphilis increased, especially among Broward residents, no increase in knowledge was observed among survey participants (Table 2 [triangle]). The mean test score was 7.7 ±2.8 correct answers (out of 12 questions) at baseline and 7.5 ±2.7 correct answers at follow-up. Low scores at baseline and at follow-up were often attributable to many (up to 48%) “not sure” responses.

Perceived chances of becoming infected with syphilis increased from 3.5% at baseline to 10.8% at follow-up among respondents from Broward but remained unchanged among men from Miami–Dade (Table 3 [triangle]). Increases in perceptions of syphilis risk at follow-up were associated with exposure to SFSC campaign materials (P < .001), club drug use (P = .002), and the use of sildenafil citrate (Viagra), vardenafil HCL (Cialis), or tadalafil (Levitra) in the past year (P = .004).

Use of at least 1 of the 3 sexual enhancement drugs was more frequently reported at follow-up by men living in Broward (28.3%) than by men living in Miami–Dade (17.6%). In both counties, higher perceptions of risk at follow-up were also held by men who had engaged in unprotected anal intercourse in the past year, unprotected anal intercourse in the past 30 days, and anal intercourse in the past year while under the influence of alcohol or drugs (P < .006).

Behavior Changes

Self-reports of alcohol use in the past year declined from 88.6% at baseline to 82.5% at follow-up among MSM from Broward and Miami–Dade (P = .02). Use of crystal methamphetamine, however, increased from 6.8% at baseline to 14.3% at follow-up among men who lived in Miami–Dade County (P = .06). Cocaine use increased significantly among Broward MSM (P = .02) but not among Miami–Dade MSM. The use of nitrite inhalants, ecstasy, and other club drugs remained unchanged at follow-up (P > .05).

The vast majority of respondents at baseline (96% of 401) and at follow-up (94.5% of 446) reported having 1 or more sexual partners in the past year (P = .38). There was no evidence that interventions introduced as part of the social marketing campaign reduced unprotected receptive anal intercourse in the past 30 days (P = .87) or any other risky sexual practices associated with syphilis among Floridians (P > .05). Contrary to expectations, reports of anal intercourse in the past year increased among Miami–Dade residents from 76.6% at baseline to 86.1% at follow-up (P = .04).

Approximately 25% of respondents in both study periods said they had met 1 or more of their partners during the past year through the Internet (P = .91). The mean number of sexual partners met through the Internet, however, declined from 9.7 at baseline to 5.9 at follow-up (P = .01).

Clinic Visits, Testing, and Treatment for Syphilis

Approximately 20% of respondents said they had visited a south Florida STD clinic in the past year (Table 2 [triangle]). During 2004, 55 survey respondents reported that they had been tested for syphilis at the AIDS Project of Florida, located in Broward County, and 56 respondents said they were tested for syphilis at either the Broward County or the Miami–Dade County health department clinic. At baseline and at follow-up, MSM from Florida who had seen 1 or more of the displayed images were more likely than those who had not to report visiting a clinic associated with the SFSC campaign (P < .001).

Testing for syphilis did not increase among Florida residents (Table 2 [triangle]). Nevertheless, Florida residents who recognized 1 or more of the 5 SFSC campaign images at follow-up were more likely than were those who were unaware of the campaign to report being tested for syphilis (44.8% vs 28.2%; P=.002).

Treatment for syphilis increased from 2.0% of Florida residents in winter 2004 to 5.3% in the fall (Table 2 [triangle]), but the increase from 6 men treated at baseline to 21 men treated at follow-up was not statistically significant. Floridians who reported being infected with HIV were not more likely than were non–HIV-infected Floridians to perceive themselves to be at risk for syphilitic infection, but they were significantly more likely to be tested for syphilis at baseline (P=.001) and at follow-up (P=.01), and they were more likely to report being treated for syphilis at follow-up (P=.005).

DISCUSSION

The first attempt to eradicate syphilis in the United States began in 1961 and was terminated in 1972 after the Washington Star published an article describing the Tuskegee Study of Untreated Syphilis in the Negro Male.24 The eradication effort was based on a 6-point program that included the introduction of behavioral research into STD prevention and control.25 The current 5-strategy elimination program continues at some level, but in south Florida, the social marketing campaign to prevent syphilis ended abruptly—and the SFSC disbanded—when CDC funding ceased in December 2004. The CDC’s current syphilis elimination program suffers from the same lack of national commitment and investment of resources that characterized the syphilis eradication effort of the 1960s.

In theory, social marketing includes consumer orientation, data-driven decisionmaking, and scrupulous attention to the 4 “P’s”: product, price, placement, and promotion. In public health practice, shortcuts are often taken. In the original budget of $1 029318 submitted to the CDC, only $5000 was allocated for evaluation. When CDC reviewers recommended that the scope of work incorporate more-rigorous evaluation, 10% of the revised budget was allocated so that other campaign components would not be sacrificed. Social scientists that subsequently joined the SFSC to conduct process and impact evaluations looked at the demonstration project for theoretical integrity and proof of effect, whereas practitioners sought to implement a “powerful and sustained” campaign with “appealing and dynamic” messages and to demonstrate efficacy through “client satisfaction surveys” (as described in the Department of Health’s scope of work).

Under ideal conditions, baseline surveys would have been completed in December 2003, interventions would have been introduced in January 2004, and follow-up surveys would have been collected in December 2004, after all interventions had been introduced. Those responsible for implementation saw the White Party as an opportunity to jump-start the campaign, and they introduced SFSC materials (featuring Adora) in November, before any baseline data could be collected. Other items (In the Dark and Hot Sex!) were also in circulation when the evaluation team entered the field in February 2004. Thus, the short-term evaluation was unable to establish baseline measures before the campaign was launched and to collect follow-up measures exactly 12 months later.

Unlike the retrospective evaluation of the Healthy Penis campaign conducted in San Francisco,14 the impact evaluation proposed for south Florida MSM was considered to be research that required human participants review and approval before implementation. The institutional review board application and review, training and certification of field staff, and notifications of approval delayed baseline data collection in south Florida for 3 months after the first campaign items were released. Although no baseline data were collected before the SFSC campaign was launched, data from south Florida can be compared with the cross-sectional data collected in San Francisco 6 to 8 months after the Healthy Penis campaign was launched in June 2002.

Results suggest that the campaign in San Francisco was considerably more successful than the SFSC campaign in reaching MSM. In San Francisco, 80% of 244 gay and bisexual men surveyed in targeted neighborhoods indicated that they were aware of the Healthy Penis campaign; 46% of those aware (and 26% unaware; P = .009) of the campaign reported being tested in the past 6 months.14 Only 21.2% of Florida residents at baseline (3 months after launch) and 38.8% at follow-up (9 months after launch) indicated on a self-administered questionnaire that they had seen any of the SFSC items when presented with campaign images. Nevertheless, 44.8% of those aware of the campaign in south Florida said they had been tested for syphilis in the past year, significantly more than those who were unaware of the campaign (28.2%).

Lower exposure to campaign materials in south Florida might be attributable to the greater diversity and geographic dispersion of the MSM population, higher population mobility, or perhaps, campaign characteristics. The population of south Florida is one of the poorest and most diverse in the United States.26 We offered men visiting shops, bars, beaches, and clubs in south Miami, South Beach, Liberty City, North Miami, Wilton Manors, and elsewhere in Fort Lauderdale an opportunity to enroll in our study and may have succeeded in obtaining a more heterogeneous sample of MSM than that obtained elsewhere.

In South Beach, a cross-sectional study of MSM conducted in 1996 showed that none of the 205 participants had lived there for more than 11 years.27 By contrast, the average length of residency of MSM enrolled in the San Francisco Men’s Health Study was 14 years.28 In addition, the SFSC was instructed by the State of Florida Department of Health to “reach all populations at risk.”11 Consequently, impact on those at greatest risk may have been attenuated. Campaigns that focused exclusively on MSM appeared to be more effective.29,30

Recognition of campaign materials in San Francisco was associated with reports of syphilis testing in the past 6 months, but so were other variables, such as being HIV positive and having casual partners.14 MSM who were tested for syphilis may have been tested by their medical providers because of these and related factors and not because they saw marketing materials that motivated them to visit a clinic and request a test. In south Florida as well as in San Francisco, the temporal sequence could not be established; testing for syphilis may have preceded campaign awareness.

Although our evaluation produced some evidence of the social marketing campaign’s impact on MSM living in Florida, none of the 8 primary campaign objectives were fully met. Exposure to campaign materials increased over the 6-month study period. Men in Broward County became more aware of and concerned about syphilis. But recognition of campaign materials among MSM in south Florida was considerably lower than the levels of 58.5%31 to 80%14,30 reported elsewhere, and no improvements in syphilis awareness or risk perceptions were observed among Miami–Dade residents. At the community level, syphilis knowledge scores remained unchanged, and no statistically significant increases in clinic visits, testing for syphilis, or treatment of syphilitic infections occurred as a result of the SFSC social marketing campaign.

Acknowledgments

Earlier versions of our process and impact evaluation reports of the South Florida Syphilis Coalition (SFSC) social marketing campaign were presented at the 16th Biennial Meeting of the International Society for Sexually Transmitted Diseases Research in Amsterdam, the Netherlands, on July 13, 2005, and at the National STD Prevention Conference held in Jacksonville, Fla, on May 10, 2006.

We are indebted to the Bureau of STD Prevention and Control, State of Florida Department of Health, for inviting us to evaluate the SFSC social marketing campaign; to Al Menard and Rob Strauss for supervising fieldwork; and to Brett Miner, Yamile Marrero, Thor Barraclough, Stephannie Thacker, Juan Moreiras, Paola Montes, and Jenny Bailey for volunteering to assist us with data collection and analysis. Marc E. Cohen and Robyn Vandenberg of the United Foundation for AIDS; J. Franklin Fletcher, our liaison with the Bureau of STD Prevention and Control in Tallahassee; and many members of the Broward and Miami–Dade county health departments were wonderful colleagues who assisted us whenever we asked for their help. Richard B. Rothenberg of the Institute of Public Health, Georgia State University; Thomas Valente of the Keck School of Medicine, University of Southern California; and Michael Gross provided critical reviews and offered many helpful suggestions on earlier drafts of our final report.

Human Participant Protection
Research protocols for baseline and follow-up evaluation studies were approved by the institutional review board at Florida International University.

Notes

Peer Reviewed

Contributors
W.W. Darrow designed the evaluation plan, developed the research protocol, prepared data collection instruments, obtained appropriate reviews, trained students and field staff, supervised data collection, analyzed and interpreted survey data, and drafted the article. S. Biersteker assisted with all aspects of the research process, coordinated fieldwork, and contributed to the writing and editing of the final article.

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