The use of a confrontational approach in HIV prevention
By Franz Trautmann
It has been pointed out from various sides that the general HIV prevention campaigns have not been successful at reaching so-called 'youth at risk' (Jezek 1991; Buning/Trautmann 1993). This is true not only in the Netherlnads but also in other countries. Risk factors are sexual behaviour as well as experimental drug use. A particular problem is that these young people seem to value safer behaviour less and engage in more risk taking. There is little, if any, specific prevention material available for this target group. Prevention approaches are not sufficiently geared to it's life style.
In the past few years, in the Netherlands several organisations have tried to approach the target group. An example of this is the Rubber-in-the-House campaign of GVO Amsterdam (Jezek 1991). Moreover, some of the materials designed for young people in general turn out to appeal to 'youth at risk' also. Examples of this are 'Check it Out' (Beumer e.a. 1991), the 'vrijkaartje' (which means free ticket but also ticket to make love, it has been designed as a free ticket including a condom) of the STD foundation and the 'Stop AIDS, vrij veilig' leaflet (safer sex promotion) (Poelman 1992).
In most of the educational material about HIV/AIDS for young people, however, no attention is paid to the risks of intravenous drug use. With a few exceptions in which safer use is mentioned (like in the AIDS prevention activities workbook for youth workers 'About AIDS and Sex' (Freericks and Van de Vegte 1993), the material is restricted to safer sex. In HIV prevention materials for young people the use of drugs or alcohol is only mentioned in connection with its possible negative influence on safer sex.
A problem with targeting this group is that they are difficult to define. The different names given to this group, including: 'youth at risk', 'marginalised youth' and 'problem youth', highlight this vagueness. They have problems at several levels, like school, work, family, housing, free time and police. Also being in circles of beginning intraveneuos drug users is a risk factor. However, one can identify these possible risk factors. Furthermore, we do know how and where to find them. In the Netherlands, they can be found in - among others - popular bars/cafes, disco's, hash smoking 'coffee shops', etc.
As HIV prevention campaigns up till now generally failed to reach these group, one has to look for a suitable, appealing formula to get through. The target group we discuss here seems not to be interested in a 'soft', 'gentle' or 'moralistic' approach to prevention material. This, however, has been the basic tenor of HIV prevention campaigns in the Netherlands. Only recently the tone of the messages bacame stronger. Campaigns like "No-one has ever caught AIDS from a bit of understanding" to the more explicit and horny: "I have safer sex or no sex."
Some experiences with HIV prevention for the target group in question and interviews with some of its members show that a hard, confronting approach combined with humor might appeal to them (Roks 1991, Trautmann/Buning 1993, Trautmann 1992). They like to be tough, they are fond of cynical jokes.
Therefore, the Project AIDS and Drug Use at the NIAD (The Netherlands Institute for Alcohol and Drugs) and Mainline (a foundation for health and prevention work among drug users) have been looking for ways to test a confronting HIV prevention approach for this target group. Considering the possibilities for such an approach, it has been clear from the beginning that in view of the objections against and the negative experiences with a solely hard approach, scaring people should be avoided. Among others, a number of British AIDS and drugs prevention campaigns that use the hard approach (confrontation with death and illness) have shown that campaigns that evoke (solely) fear in general do not have the desired effect. This is one of the reasons why in Dutch campaigns so far a more positive approach has been used, suggesting alternative behaviour. Recently there have, however, been different campaigns like posters appearing in the streets with the text 'AIDS the Deadly Bite of Love' or the mobile advertisement of Freestyle condoms with a bill board size picture of a penis with the text 'Prick, use it'.
In general, advertising aims for positive emotions and associations. But recently there have been a few examples of advertising campaigns that have chosen for a confrontational and fear inducing approach.
On the basis of these findings NIAD and Mainline have chosen for a combination of confrontation and humor, which - as an approach that does not bluntly evoke but refer to fear - seems to offer possibilities. Here it is worth realising that in AIDS prevention, 'fear' always plays a role. Even the most docile campaign confronts the observer with the four lettered acronym AIDS. Fear of dying is in fact one of the reasons for people to use a condom when having sex. It is not a question of whether or not to use scare tactics - it is a matter of how to dose and cloak it.
As medium Convenience Advertising has been chosen as it offers opportunities to bring a select message to a specific target group - hence the term, 'narrow-casting'. The medium involves the strategic placement of small framed posters in the toilet cubicle and washroom area of selected locations: ensuring that visitors view information at their 'leisure' without fear of being 'spotted' by peers. In this way a sort of personal contact is created (Mugford 1992). By making a good selection of the venues, one knows who will get the message and who will not. Because no outsiders are listening, the target group can be adressed in their own language. Among homosexuals you can use the word gay, for the general public you have to talk about men with homosexual contacts. 'Narrow-casting' offers the possibility to specifically tailor the message to suit the target group. This means that one can be more direct than in a billboard campaign that is seen by the general public.
As both the medium and the approach have not been used before in this field in the Netherlands the choice was made for a pilot project, including a thorough evaluation. The pilot was meant to function as a 'reminder' for the target group. Transfer of knowledge was not the main aim, rather it was drawing attention to safe behaviour and convincing people that the message is relevant for them also.
After having investigated the possibilities of a pilot project in coffeeshops in Amsterdam and after consultation with representatives of organisations in Rotterdam, the section AIDS and Drugs of the AIDS platform and the Drugs Prevention Platform in Rotterdam, it was decided to develop a project proposal to use in Rotterdam. The project has been a joint activity of the following organisations:
· Convenience Advertising
· Rutgers Foundation for family planning and sexuality.
To ensure that content and execution of the project were geared to the situation in Rotterdam a steering committee had been formed of representatives of the above organisations and respresentaives of the Municipal Health Service of Rotterdam and Odyssee/HADON, a drug service in Rotterdam.
Due to the fact that the camapign was not aiming at drug users but at young people who might experiment with drug use it had been decided that the pilot would stress the importance of safer sex. Safer use played a minor role.
Based on the actual situation in Rotterdam, 63 locations had been selected for this pilot project. As suitable locations for a campaign for young people at risk places of entertainment like cafes, discos and (hash) coffeeshops were selected. In selecting the coffeeshops, those were chosen that do not have an exclusive 'soft drugs image', in other words they do not only sell soft drugs but alcohol also. It should be noted that in Rotterdam the distinction between places where soft drugs are sold and those that sell alcohol is less strict than in some other towns.
For the pilot project it was important that the places, like other establishments and youth centres play an important role in the leisure activities of the young persons. Leisure time in this case is not only time officially allowed but also time that is taken against the rules. Truants, and young persons who have problems at home, regularly frequent establishments that appeal to them and that are open in the day time. This also appears from the experiences of outreach youth work. (Folkers 1991). Skipping school, or more general, problems at school or at home are important factors in the definition of the target group 'young people at risk'.
Although the target group is also found in facilities like youth centres, centres for truants and part time education, for two reasons these locations were not used in the campaign. First, education and community work often pay attention to HIV prevention already. Second, it is possible that the target group will experience information through these canals as negatively, for example uninteresting or paternalistic. An approach via the favourite places of entertainment was expected to be considered neutral or even positive.
Having done some initial stock taking and having visited some of the suitable locations, the contents of the campaign were fixed. It was decided not to follow the original idea of making sex-specific posters. Several of the selected locations appeared not to have separate male and female toilets. The idea to make posters with more detailed information for ordinary toilets and more concise ones for doors or urinals was rejected also. People turned out not to stay longer in ordinary toilets that at a urinal. This is probably caused by the fact that the toilets are used only to urinate. Also a number of toilets were rather dark.
The above led to the choice of posters with a short text, addressing both sexes. As the aim of the posters was to convince and remind the target group that the message is relevant to them, too, it was decided the design should be aimed at drawing attention. Youth of today are bombarded with an enormous amount of messages: AIDS is one, among a cast of thousands. To really grab the viewers attention - a message has to stand out. In advertising, a 'lifestyle' context is central to speaking effectively to your target group. Therefore the search was for a striking, eye catching, attention drawing design. In consultation with an advertising agency, a combination of a short appealing texts with an unambiguous message and a striking picture was chosen. A confrontational approach fitted wel in this framework.
At face value the target group is offered an attractive proposition, like: "How do you get a free ride in a Chevrolet?" The answer lies in a stylish black and white photo - a hearse in a funeral parade. The photo gives the message an ironic touch and reinforces the tagline, "AIDS. Without a condom you're a dick head." The target group is confronted with the outcome of unsafe behaviour, and this outcome, creates fear. The use of 'black' humour in the message allows the observer a way out. This helps prevent fear from undermining the message which may result in the observer rejecting it. The confrontation and directness of this type of message fits in well with graffiti culture.
Ten concepts utilising this approach were focus tested with twenty members of the target group in two cities in the Netherlands. The approach and the messages tested well and were understood. A few participants offered spontaneous suggestions and modifications. One suggestion was later used in the campaign.
On the basis of the pre-test results, a number of messages were modified or skipped. It was also decided to include information about the ways of transmission and about the availability of condoms and addresses of where condoms could be bought anonymously (outside vending machines).
In april 1994 the pilot campaign was started for a period of 6 monthes.
Mijn voorstel voor dit deel is dat wij beginnen met de reacties van de professionals. Daaraan aansluitend kunnen wij ingaan op de hoofdpunten uit Peter Blanken's evaluatie. Ter afsluiting kan een aantal conclusies/aanbevelingen worden geformuleerd. Het door Tijs op papier gezette verhaal biedt hiervoor bruikbaar materiaal (zie onderstaande tekststukken). Hierover hebben wij nog contact.
Youth workers and field workers applauded the concept and approach. The owners and workers in the selected locations were also very enthousiastic about the strategy. These 'gatekeepers' thought the campaign was 'fun' and necessary, which in turn fostered the access to the target group. The installation of condom vending machines by owners and managers of these locations revealed their commitment to the campaign. At the commencement of the campaign only 8 of the 63 locations had vending machines. As a result of the campaign, a further 10 had machines installed with another 18 locations contemplating doing the same.
The reaction of professional health educators and policy makers was not so favourable. The most important arguments presented were:
1 "You are using fear tactics although there is the consensus in the Netherlands not to do so."
This campaign is not about creating fear. The approach uses a combination of confrontation and humour. Furthermore this argument shows how destructive consensus can grow. Over the years it can become a set of rules which cannot discussed anymore, instead of a shared vision.
2 Young people in the Netherlands are well educated and extra attention is unnecessary.
While understanding about AIDS may exist, this does not necessarily mean that behaviour change will follow. A person interviewed for the evaluation sais it quite simple, "I know all about it, but I am dumb enough to need a kick in the pants every once in a while".
3 The campaign is too shocking and hurting
The reader determines how much he or she is shocked by the message content. The official criticism by professional health educators could be true if the posters were widely displayed on billboards. But this was not a mass media campaign. By using Convenience Advertising we were able to ensure that the target group were the only people who saw the message. At risk youth were not shocked by the campaign - health professionals obviously were.
Narrow casting ensured that hardly any HIV positive people saw the campaign messages. This argument turned out to be a non-issue anyway. At the end of the campaign, two messages were printed in HIV News - a magazine for HIV positive people in the Netherlands. There was not one negative reaction to the messages.
4 A Follow-up campaign will need to be even more 'shocking. Where will it end?
It is not true that once you have used confrontation you need to go further with that concept. The follow-up campaign to this pilot project, will contain more text and information for young people about risk reduction strategies. An example of our follow-up message may include a 'banter' between two people about condom use, with strategies and trics for discussing and practising safer sex. The follow-up campaign will also contain sex-specific messages for men and women. The tone and text of the campaign will speak to the target group in 'their' language and not that of the general community.
In general, it is always difficult to predict how to proceed further. The context changes: and as educators we always need to 'keep up with the times' and check what new opportunities have arisen and what strategies are effective. Forward projections are useless: even big advertising agencies will not attempt to predict the future climate.
The open resistance of professional health educators to the 'pilot project' was remarkable considering it's aim was to test the effectiveness of the medium (Convenience Advertising) as well as the confrontation/humour approach. Through lack of curiosity and open dialogue the financial backing for the evaluation was frustrated. Instead of an influx of money to distil doubts about the effectiveness of the approach, less money was made available for research.
The focus of our campaign was on 'risk factors': both the seriousness and the chance of threat. We needed to convince our target audience, 'at risk youth', that AIDS is also something that can happen to them. It was therefore necessary that the 'messenger' was trustworthy. The context, tone, and humour all needed to reflect the culture and lifestyle of the target group. To use the terms of the Greek 'rhetoric': the listener will only be convinced of the rational content (logos), if he/she has enough respect for the speaker (ethos) and if the speaker uses enough 'sentiments' (pathos) such as fear and humour. Both ethos and pathos are situationally determined and are different for every sub-culture.
Confrontation alone is not sufficient. The observer of the message also needs to be presented with an alternative behaviour. The tagline, "AIDS. Without a condom you are a dick head" offers an alternative. The effectiveness of using condoms (expectation of the solution) is accepted in this target group. The expectation of self effectiveness of Rogers will be further developed in the follow-up campaign.
Peter Blanken, a researcher at the Rotterdam Institute for Addiction Research (IVO), has presented the official results of the evaluation yesterday on this conference. The evaluation was conducted with 280 members of the target group. I would like to highlight some overall results of the research: 85% of the interviewed target group spontaneously recalled the tagline and 70% thought the message content was clear. The messages prompted a lot of discussion between visitors at the participating locations. Shortly stated, the campaign made an impact.
In saying this, there is also a section of our target group that we didn't reach: the group that doesn't respond to any 'official' message. They share a feeling of being 'losers' and racist attitudes. It is difficult to know exactly how big this group are and in what sense they are taking risks with the sexual transmission of HIV.
Maybe for this group the message needs to be more 'direct' and more 'tough'. Or maybe an attractive poster with text reeks already too much of officialdom and government interference. This alone could be enough of a signal for this group to switch off. A more comfortable approach could be a combination of oral and written prevention strategies. The posters could then be used by fieldworkers as a prompt to begin a conversation, the so called agenda setting.
What we learned from this campaign:
1 Look, listen and learn from your target group. A field study is absolutely necessary - even if it is just to discover that the toilets are badly lit. The concept of the campaign needs to be tested with the target group in their own environment. A large focus test is not necessary, between 10-20 reactions wille mostly give a good impression. This is providing of course that you have chosen representative people from your target group.
2 The credibility of the 'sender' is an absolute condition for an effective campaign. In practice far too little attention has been paid to the credibility of the sender.
3 With narrow-casting you can more finely tune your campaign to suit the target group. This strategy also allows you to take more risks and be more provocative. In this way, ethos and pathos can be better used. Because fear and confrontation are subjective factors.
4 The attempt to reach consensus about an approach causes a watering down effect of the message and campaign. It diminishes the input of the target group and kills the creativity.
5 Fear of the opinions of funding organisations can lead to (self)-censorship. Too much political correctness towards HIV positive people has the same effect.
6 With AIDS prevention too little attention is paid to new trends in advertising and marketing. In these areas we can find know-how and expertise and on the same time AIDS campaigns have to compete with regular advertising media.
7 Our target group is not homogenous. We can recognise at least three different sub-groups. It would be interesting to develop more variations of the posters and selectively target our messages to different hash 'coffee shop', bars and disco's.
8 Fear and confrontation are means, they never can be an aim in itsself. Shocking because of the shocking doesn't work. Also a confrontational approach has to take the feelings, subculture and norms af the target group as the starting point. The hard anti drugs campaigns don't follow this rule and therefore they are not effective.
9 Professional health educators are very frightened about using fear as a prevention strategy: At the same time the target group is saying that campaign messages can't be tough enough. To develop a campaign is above all an act of balancing. Balancing between health educators
and the 'person in the street'. Between intuition and big scale evaluations. Between national consensus and a being 'bloody minded'.
It is not a question of whether or not to use scare tactics - it is a matter of how to dose and cloak it. Insensitive confrontations are useless; measured confrontations on the contrary, are not. Consideration needs to be paid to what is the target group, what is the most effective medium to reach your target group, what is their 'culture', habits, situations etc. AIDS prevention campaigns that were 'scary' five years ago may well have a different effect now.
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