Healthy Penis: San Francisco's Social Marketing Campaign to Increase Syphilis Testing among Gay and Bisexual Men

The authors describe the development, implementation, and evaluation of their innovative social marketing campaign.

"Click It or Ticket" campaign aimed at increasing seatbelt use, Florida's "truth" anti-smoking campaign, and the United States National WIC (Women, Infants and Children) Breastfeeding Promotion project [4].
The impact of a social marketing campaign is evaluated based on the measurement of change in the targeted behavior, i.e., increased syphilis testing in the case of Healthy Penis, and the extent to which this change is associated with people who received the campaign messages. To that end, we initially evaluated the Healthy Penis campaign in 2002-2003 and found a higher rate of syphilis testing among those aware of the campaign than those unaware of the campaign [5]. In addition, syphilis knowledge was higher among those aware, a secondary goal of the campaign.
In this article we describe the development, implementation, and evaluations of the Healthy Penis campaign. We present a simple method to evaluate the immediate and long-term effectiveness of a public health media campaign designed to change behavior. We include our most recent evaluation, conducted in 2004-2005, which assessed the longterm effectiveness of the campaign [6] and determined if respondents aware of the campaign 2.5 years after it began displayed the same syphilis knowledge and testing behavior as those initially aware of the campaign in the fi rst evaluation.

Healthy Penis Campaign Development
The Healthy Penis campaign was launched during the annual San Francisco Lesbian Gay Bisexual Transgender Parade in late June 2002 and continued through December 2005. A San Francisco-based social marketing fi rm, Better World Advertising, created the campaign in collaboration with the SFDPH to target the gay and bisexual community. This campaign was part of a broad multifaceted effort begun in 1999 by the SFDPH in response to the syphilis epidemic [7].
The campaign was developed in collaboration with the Los Angelesbased Stop the Sores syphilis prevention campaign, which allowed us to lower our start-up costs to $75,000 in 2002. The campaign was continued through the end of 2005 at an additional cost of $295,000 [7]. Three-quarters of the campaign's fi rst-year funds were spent on campaign development, with the remaining quarter spent on displaying campaign materials [8].
Syphilis is often initially asymptomatic and testing is readily available in San Francisco for easy diagnosis. Based on these characteristics and input from the community partners group, the SFDPH determined that the primary campaign health behavior message should be "get tested," with the main objective of changing community norms around syphilis testing. Secondary objectives were to increase awareness about the syphilis epidemic in gay and bisexual men and to increase knowledge about syphilis (symptoms, routes of transmission, the link between syphilis and HIV transmission, and so on). The complete methodology for selection of campaign concepts and themes for this campaign has been described in a previous manuscript [5].
The Healthy Penis campaign was promoted in neighborhoods where the greatest concentration of gay or bisexual men lived and where there were businesses that catered to this population. The campaign incorporated the use of humorous cartoon strips that featured characters like Healthy Penis and Phil the Sore to: (1) promote syphilis testing, (2) publicize the rise of syphilis among gay and bisexual men, (3) provide information on syphilis transmission, symptoms, and prevention, and (4) delineate the connection between syphilis and HIV ( Figure 2). These cartoon strips were initially published semi-monthly in a popular gay Bay Area publication. After publication, poster-size reproductions were posted on the streets; in bars and commercial sex venues; on bus shelters and bus advertising; on palm cards; and on doi:10.1371/journal.pmed.0030474.g002  banner advertisements on one of the most popular Internet sites for meeting sex partners among gay men. Topics addressed in campaign cartoons initially emphasized all four areas described above and then after 1.5 years focused primarily on the message "get tested." In addition to messages contained within the cartoon strip, brief text boxes were displayed on the bottom of the cartoon images describing modes of syphilis transmission (skin-to-skin contact, oral, anal, and vaginal sex), symptoms (painless sore and/or rash), and explaining that syphilis is curable. Respondents were asked about basic demographic information; unaided (e.g., spontaneous mention) and aided (e.g., prompted response) awareness of the Healthy Penis campaign; perceived key messages of the campaign; syphilis knowledge (via open-ended questions); sexual practices in the past month; HIV status; and how many times they were tested for syphilis in the past six months.
Comparisons were made among those aware of the campaign between the fi rst and second sample of respondents. Recent history of syphilis testing was compared with campaign awareness level for each evaluation separately. Analysis included Fisher's Exact and Cochran-Armitage tests, and logistic regression.
Survey population. Two hundred and forty-four interviews were conducted with San Francisco residents and included in the fi rst evaluation; 150 interviews were included in the second evaluation. For each evaluation, all respondents were men who have sex with men (MSM) and most were white and HIV negative. Our respondents were similar to the MSM population in San Francisco. More detailed characteristics of the two samples are described in Table 1. There were no signifi cant demographic differences between Evaluation I and II participants.
Campaign awareness. Campaign awareness was high with 80% (n = 194/244) and 85% (n = 127/150) of respondents aware of the campaign in Evaluation I and II, respectively. Unaided and aided awareness was similar between the two evaluations; 33% versus 41% spontaneously mentioned the Healthy Penis campaign (unaided awareness) when asked to recall recent advertisements or public events about sexual health issues, and an additional 47% versus 44% recognized the campaign (aided awareness) when shown a campaign image (Evaluation I and II, respectively). There was no difference in overall campaign awareness, unaided awareness, or aided awareness between the two evaluations (p = 0.23, p = 0.13, p = 0.60, respectively). Among respondents aware of the campaign, campaign exposure was greater in the fi rst evaluation; Evaluation I respondents reported a median of six exposures (mean, 18) over the previous three months, while Evaluation II respondents reported a median of fi ve times (mean, six) in the previous three months (Wilcoxon two-sample test, p < 0.0001). Perceptions of key messages among respondents who were aware of the campaign did not change markedly between Evaluations I and II, with the most common message identifi ed being "get tested" (53% versus 55%, respectively, p = 0.73).
Syphilis testing in the last 6 months. Both evaluations found a positive association between campaign awareness and recent syphilis testingthe primary objective of the social marketing campaign. An increasing proportion of respondents reported syphilis testing in the previous six months by campaign awareness level (none, aided awareness, and unaided awareness): Evaluation I: 26%, 40%, 55% (Cochran-Armitage trend test z = -3.303, p = 0.001); Evaluation II: 35%, 42%, 60% (Cochran-Armitage trend test z = -2.304, p = 0.02) ( Figure  4). After controlling for potential confounders (age, HIV status, casual sex partners in the last month) in a doi:10.1371/journal.pmed.0030474.g003  Overall, reported syphilis testing in the previous six months did not change from the fi rst evaluation to the second evaluation (42% versus 49%, p = 0.25).
Syphilis knowledge. There were few signifi cant differences between evaluations among respondents aware of the campaign in terms of knowledge of syphilis, including knowledge of symptoms; groups most affected by syphilis; how to fi nd out if you have syphilis; health consequences of untreated syphilis; and the relationship between syphilis and HIV acquisition and transmission (Figure 3). Syphilis incidence. In 2005, incidence of early syphilis was lower than in the previous three years, with decreases in cases in gay/bisexual men accounting for the drop [9]. Although our campaign evaluations were crosssectional and causality cannot be determined, it does appear that the Healthy Penis campaign, along with other SFDPH syphilis elimination efforts [7], may have led to this decrease in syphilis incidence.

Conclusions from Evaluations
MSM who were aware of the Healthy Penis campaign were more likely than those unaware to have recently tested for syphilis and to have greater knowledge about syphilis. This effect was sustained for almost three years.

Next Steps for Healthy Penis
After initial evaluation of the Healthy Penis campaign, elements have been used in Philadelphia, Seattle, Palm Springs, and Santa Clara County, California (www.healthypenis.org).
Thus the campaign can be translated to other jurisdictions. Because much of the material is already developed, other jurisdictions may adapt and use the campaign at a lower cost than was originally incurred in San Francisco, although they will need to conduct evaluations to ensure the campaign is effective for their population. In addition, the principles used in the development, implementation, and evaluation of Healthy Penis are universally applicable for any social marketing campaign.
Based on our experience with the Healthy Penis campaign, we believe spending more start-up resources on campaign development rather than campaign placement [8] was probably what led to our high level of campaign awareness, demonstrating that our campaign resonated with our target population. We also learned that partnering with another jurisdiction (Los Angeles) lowered start-up costs and creating a Community Partners Group helped us tailor our campaign messages to be most effective. And most importantly, we learned that careful, well-planned evaluations are critical in assessing the impact of a campaign, which then supported continuing the campaign and implementing it elsewhere. Our evaluations strongly suggest that the Healthy Penis social marketing campaign was effective in augmenting syphilis testing and increasing syphilis awareness and knowledge in the San Francisco gay and bisexual community. This effect might have contributed to decreased syphilis incidence in 2005.