New THT ad takes tired old approach

Britain’s largest HIV organisation, Terrence Higgins Trust (THT), has just launched a new safe sex campaign advertisement, misleadingly titled “Condom Moment”:

New it may be, but it feels awfully familiar.  For reasons I’ll explain, as a piece of marketing it makes literally no sense, but as a safe sex advertisement, it’s totally recognisable.  That’s interesting in itself: it suggests the safe sex campaign has become a genre.  Like harrried-mum-with-air-freshener and car-on-a-winding-road-with-Sting-or-Enya clips.  No longer trying to persuade anyone of anything, you’re just taking up time before you shove your logo in front of the audience to maintain brand recognition.

That sucks because it seriously constrains your options for future innovation.  It’s like the joke about two old men who’ve been fishing together for so long they have numbered their jokes.  “No. 45! — and they both fall about.  A new guy tries it on, “no. 92!” and they scratch their heads: “Are you sure you’re telling it right?”

As marketing this piece makes no sense because it’s a condom ad that fails to sell condoms.  It starts with couples getting frisky in unusual places, then presents a slow-motion montage of grim faces, frowning, anxious, fearful, awkward, pulled out of the moment by a rising crescendo of worried whispered thoughts.  As a fairly think-y person, this resonated with me; it often takes me a while to shut down my brain and just get in the moment.  But then the ad ends and coloured text appears, telling the viewer to use condoms.  And that’s not an ending, it’s a Powerpoint slide.  Whatever happened to ‘show, don’t tell’?

The ad could have shown one of the partners whipping out a condom and the other showing visible relief and redoubled enthusiasm as their worries evaporate and they get back into the moment.  You know, actually marketing the product, i.e. condoms, and the benefit, worry-free sex.  Instead, they stuck to the genre of the safe sex PSA, concluding with an imperative textual instruction.  At which point I was literally shouting at my screen and calling for the campaign manager’s head… I really need to dial back my coffee intake.

In the comments, someone objected to the stereotype of gay men getting it on in a toilet, and THT made a very telling remark in reply:

We agree it would have been fantastic to have more couples in different locations, but – with a limited budget and tight schedule – we understand why the team who donated the clip had to focus on the most visually compelling shots.

As a social marketer this rang some Big Ben-sized alarm bells for me.  ‘Donated’ is not a good word in this context.  It’s hard enough getting an agency you’ve commissioned to stick to the brief, as I have personally and recently experienced, but it’s even trickier when the agency is donating the work.  You need a lot of clarity in the roles each party will play in co-constructing the message.

In this film, there is some evidence of front-end input of focus group or interview findings on the reasons people give for not using condoms, but it flubs the ‘product P’ — one of the most basic elements of the marketing mix.  It looks like the film maker was either briefed badly or didn’t take the brief, but it ends with the THT logo and so they’re ultimately responsible for it.

Capturing diffusion in action

In social marketing, diffusion is the hidden premise in nearly all our campaign strategies.  After all, we set population-wide objectives for campaigns only funded enough to reach a tiny fraction of society at large.  So if only 1-in-10 or 1-in-100 of our target audience actually sees our message — and I’m being optimistic here — how could that influence the other 9 or 99?  The implicit assumption is usually that our message will ‘diffuse’, i.e. spread onwards and outwards through word of mouth.

There’s a theory that supposedly describes how this happens: Rogers’ (1962) Diffusion of Innovations theory.  He studied how farmers came to adopt new technology for automated farming, and why some picked it up really early and others waited a really long time.  He graphed the adoption curve and divided it into segments: innovators, early adopters, early and late majority, laggards.

The implication for someone who wants to start a trend is that you need to identify the early adopters in a population — people who have LOTS of social connections — and convince them, and then the other segments will follow like dominoes.  This was certainly the message of Malcolm Gladwell in his book The Tipping Point, and both Gladwell’s and Rogers’ theories have turned up in massive RCT studies of community-level HIV prevention interventions, like Project Accept (Khumalo-Sakutukwa et al, 2008).

The problem is both theories are wrong.

Rogers just takes the normal curve and labels the standard deviations A, B, C, etc, and then assumes because A before B therefore A causes B.  Post hoc ergo propter hoc.  Gladwell assumes spread is determined by characteristics of well-connected, charismatic people (like himself).  But as Duncan J Watts demonstrated in real time using 16 separate bunches of real people downloading, sharing and rating digital music tracks, it’s not about particular well-connected individuals, it’s about having a large proportion of easily influenced people that matters (Watts, 2001).

To use a disease metaphor, we’re not looking for superspreaders like Typhoid Mary — it’s about what proportion of your population are vulnerable (ie. not immune) to the message you’re trying to spread.  This poses all sorts of really interesting questions for campaign planners.

One is:  what would information immunity look like?

And another: how would I track diffusion of my idea?

At a very superficial level, as Tyler Cowen Horan has shown, it’s possible to measure diffusion of links or hashtags on social networks like Twitter, using automated content analysis tools like OpenCalais and the publically available feed of all tweets for a given keyword.  That will give you a quantitative and social network view of the spread of a particular marker of an idea.  But it won’t give you any clear sense of how people are making sense of it.  That first question — information immunity — complicates the hell out of the second one.

So I was interested to see friends on Twitter discussing changes to the Healthy Kids Check as reported in a Fairfax news article:

Preschool mental health checks by Jill Stark (SMH, 10 June 2012)
THREE-YEAR-OLDS will be screened for early signs of mental illness in a new federal government program that will consider behaviour such as sleeping with the light on, temper tantrums or extreme shyness as signs of possible psychological problems.

In particular, one friend had a problem with the idea that GPs might be using a 3yo wanting to sleep with the light on to diagnose a mental health disorder.  A few different people engaged on three things I discuss here, and there was fruitful discussion about these aspects of the proposal, but my friend kept coming back to the 3yo wanting the light on.  This particular example clearly resonated with this friend’s strong concern about the pathologisation of natural processes in parenting and child development.

For my part, I noted that it’s about identifying known precursors or risk factors for future mental health conditions, rather than the GP diagnosing a current disorder.  This enables a ‘watchful waiting’ approach or possibly a referral to a child mental health expert for further investigation.

My own receptiveness (lowered information immunity) to the idea was increased by having recently read, shared and discussed on Facebook an article about ‘high reactive babies‘ — a temperament with a low threshold for alarm at small changes in environment, routine, noises, smells, that predicts anxiety in adulthood.  This resonated with me personally, as a colicky baby who grew into an anxious adult with a touchy tummy and insomnia.

This research isn’t mentioned in the article but it’s clearly a really important piece of background knowledge needed to interpret the new information; without it, it’s hard to understand why a 3yo wanting the lights on is relevant to anxiety the disorder, rather than just anxiety as a normal and natural emotion known to be experienced by 3yo children in the dark.  From a diagnostic point of view, it’s not the status of the light, on or off, that matters — it’s about the intensity of the anxiety and the strategies the child uses to manage the situation and their feelings.

Another key piece of background knowledge would be knowing that diagnoses are made based on the overall picture — the constellation of elements — whereas a screening tool developed with specialist referral as the intended endpoint will tend to pick out one or two key factors that are present in most cases of the disorder.

Both aspects are presented in the article, but they are laid out sequentially in quotes from different experts.  This is journalistically unexceptionable: one is always going to have to precede the other, and it makes more sense to present concern before response, problem before solution.  The problem lies in how it presents all three quotes as equivalent in authority:

    • Prof Allen Frances, chair of the DSM-IV task force, author of a book titled Am I Okay? (Expressing concern about overdiagnosis of ADD and autism resulting from ambiguous definitions in DSM-IV)
    • Anna Sexton from East Brunswick has children aged 3, 5 and 6 who all sleep with the hallway light on (Concerned this behaviour will be viewed as abnormal)
  • However, Chris Tanti, chief executive of headspace, the youth mental health foundation (Says early intervention did not automatically lead to children being labelled; Quotes figure that only 19% of clients showing signs of mental illness end up with a diagnosis)

I guess you could argue that Chris Tanti gets the last word, but unlike in oral argument (think of the closing statement in a trial), in text there’s no guarantee the reader even finishes the article.

And thinking in terms of information immunity, let’s compare which ‘accounts’ (ways of telling the story) will seem most familiar (a key measure of susceptibility to persuasion) to an audience of parents:  they’ve read lots and lots of articles about ADD and autism and overdiagnosis, and Prof Frances appears to be arguing against his own interests as a diagnostician(+10 credibility points!); Anna Sexton has read the same articles and shares the concern of the credible Professor, so she’s a caring and informed parent;  whereas Chris Tanti is using numbers, talking about a scenario most parents don’t want to imagine ever applying to their kids, and his argument seems to suit his professional interests.  In terms of who the parent-reader sympathises with, it’s two against one.

I’m not taking a swipe at Jill Stark.  This is a conscientious, intelligent, balanced and cogently presented article about a really important policy proposal.  Setting up that closing ‘conversation’ between the quotes about overdiagnosis practically guarantees it will be discussed by parents.  It does better at provoking diffusion than most campaigns in my own field, which often foreclose on discussion by finding and presenting a ‘single [simple] minded proposition’ that nobody can argue with (and so nobody does).

But I’m worried by how that discussion played out in my Twitter stream.  I’d like for Prof Frank Oberklaid, who mentioned sleeping with the lights on, to have some way of knowing that example backfired.   I’d like for the people developing the policy to know there’s concern about a key question – who does the diagnosis, if any, the GP or a specialist?  These are qualitative questions whose answers could feed back into better communication approaches and better health policy, if only there was some way to capture them…

A modest proposal

Imagine you’re about to send out a press release about a new campaign or policy initiative.  You know it’s likely to provoke discussion, perhaps involving issues that are tricky to deal with in a standard health news article format.  You’d like to see the discussion without engaging in surveillance of semi-private spaces like @-response discussion threads on Twitter.  And you’d like the ability to answer key questions arising in the discussion — or at least to signal that you’ve heard and acknowledged them being raised.

This is not a technically difficult problem to solve.  Let’s get a consortium of health communication practitioners and researchers and journalists together; Croakey would be perfect for this.  The consortium builds a website where people launching campaigns or policy initiatives can register and create a landing page with a short URL, which they offer to health journalists to include in their articles.  Readers can follow the URL to a page that lets them ask a question and receive a notification when an answer has been posted.  They can also see other questions that have been asked, and vote on them if they had the same concern.  Answers should be written by experts involved in the policy — they need to be substantive, as people can easily see through tightly-controlled PR responses.

I’d focus on Q&A and voting, as I’ve come to doubt the discursive utility of comment threads  in this hyperpartisan era.  And I’d want to let health journalists in on access to the usage metrics it would generate — after all, they need feedback too on what issues matter and how different article structures influence understanding and discussion of their work.  In this age of the “Australian Vaccination (sic) Network” and climate change “debate”, the need for post-publication opportunities to answer questions and correct misconceptions is screamingly clear.

The status of the LGBTIQ community in 2012

This is a more or less random assortment of articles that interest me, but if I had to pull a uniting theme out of my, um, brain, it would be the status of the LGBTIQ community in the present moment.  That’s in relation to both mainstream politics in Australia and the United States and to the HIV epidemic.

1/ My Croakey post on the Queensland LNP defunding of Healthy Communities

Remember the bad old days when conservatives wouldn’t let teachers even mention homosexuality in case their students caught the gay?  Well, the LNP in Queensland is clearly stuck in that era, claiming that QAHC’s concern for such things as LGBTIQ youth suicide prevention shows it has ‘lost its way’ — even though it was encouraged and funded to do these things by QLD Health.

Campbell Newman’s government has announced plans to replace the HIV prevention programs, but not the suicide prevention ones: it would rather gay teenagers kill themselves than tolerate the public visibility of healthy homosexuals telling them it’s okay to be gay. Which leads me to…

2/ Bill Jesdale’s article on the evolution of his thoughts about gay marriage

One of the most thoughtful contributions to LGBTIQ health debate I’ve read in a long time.  In this account, gay marriage was a fight the conservatives picked with us – as Bill argues, they were looking for a political controversy that would sustain heteronormativity now that the closet doors had burst open.

What we might want to worry about, at this point, is the more sophisticated forms of social control that will inevitably emerge and follow in the aftermath of those blunt instruments, the closet and the fight over gay marriage.  They’re likely to involve new ways of pitting ourselves against each other, instead of LGBT against the Religious Right.  And they’ll be subtle, less visible.  One of them, as gay marriage rights spread around the world, is most likely going to be a new puritanism about promiscuity.

3/  An HIV-negative gay American man talks about taking PrEP

If you’re an Australian gay man, I’d love to hear in the comments if you’ve heard about PrEP yet.

PEP is short for post-exposure prophylaxis, meaning you start a month-long course of 2 or 3 antiretrovirals within 72 hours of a possible exposure to HIV infection.  PrEP stands for pre-exposure prophylaxis, where you take a 2-drug combination with very few side effects — one pill every day — before you have the sex that might otherwise cause your infection with HIV.

Given the expense of the drug, it will only be cost effective if it’s highly targeted, i.e. only available to people who would otherwise almost certainly become HIV-positive anyway.  That’s also why its longer term side effects, like increased risk of bone fracture, aren’t more of a strike against it.

When the debate about this strategy finally hits in Australia, listen carefully for all those people saying ‘why can’t those filthy barebackers just be boring married like me?’  That’ll be that puritanism I was talking about under 2/, above.  Its consequences come through loud and clear in this frank and cogent account of a PrEP experience from an anonymous San Francisco man.

Calling out name-and-shame tactics on ‘the dirty normal’

Aaron Sorkin, in a recent speech to new graduates at his alma mater, said this:

[M]ake no mistake about it, you are dumb. You’re a group of incredibly well-educated dumb people. I was there. We all were there. You’re barely functional. There are some screw-ups headed your way. I wish I could tell you that there was a trick to avoiding the screw-ups, but the screw-ups, they’re a-coming for ya. It’s a combination of life being unpredictable, and you being super dumb.

This is excellent advice.  The screw-ups are painful as hell but you live through them and learn from them, if you’re lucky.  My job, as I see it, is to help people live through the dumb years and survive their screw-ups without accumulating lifelong consequences like unplanned pregnancy, blood borne viruses, and infertility from untreated infections.

New technologies have created new kinds of consequences.  Fifteen years ago, we all used dialup and cellphones didn’t have cameras, so we didn’t have to worry about teenagers taking naked self-pics and videos and sending them to others or posting them online. It’s hard to see the harm if it’s all consensual and confidential, but there’s the rub: things change quickly in teenage relationships, and something bestowed in trust may be forwarded in anger or just plain old adolescent cruelty.

For digital natives, kids who’ve grown up online, there’s another more subtle kind of consequence to consider.  I’m born in 1981 and my generation got lucky: we posted our juvenile shit under opaque nicknames on OpenDiary, Friendster and MySpace — sites that, if not defunct, certainly don’t appear in Google search listings. Someone born in 1991 probably has all their highschool classmates on Facebook, and they’ve been posting their teenage wit and wisdom under their real names; not just on Facebook but on all the other sites that use Facebook accounts for login.

Five years from now, their employers will be searching their names and turning up comments they made at 16yo.  It’s a problem serious enough that online privacy experts have proposed letting people scrub their results from Google or even change their names at thirty — to escape from all the ill-advised stuff they said in their teenage years and twenties.  Any educator who isn’t thinking about this kind of problem for young people isn’t paying attention.

Suddenly, a wild tray of cupcakes!

I actually looked this image up at work (after asking my colleagues’ permission, of course) during a discussion about how we talk about genital diversity and female circumcision.

It’s one thing to tell people in a session that everyone’s bits are different, but nobody ever believes you; they still secretly fear ‘mine aren’t normal’.  The most effective form of reassurance is to show them that everyone is different and therefore difference is the norm.  As an educator, when you take this approach, you need to be prepared, because everyone has a reaction.  Here’s Dawn French reacting to one of those cupcakes:

 

 

Good educators let their participants react, and just as genitals are diverse, so are reactions.  In an educational session, we’d normally cover this material in single-gender groups, because boys can overdo the hilarity and say hurtful stuff to get a laugh out of their mates.  (Pro-tip, straight guys: the evolutionary purpose of sexist humour is signalling to girls that you’re not ready for sex.)  Even in female-only groups, however, participants can react in ways others find hurtful or that jar against our personal values and politics.

In an earlier post I talked about Habermas’ concept of ideal speech situations.  Thinkers like Paolo Friere and Ron Labonte suggest the goal of an educator is to create this kind of discursive environment so that the group itself can discuss and redress problematic remarks.

This calls for active facilitation on the educator’s part to create spaces where participants can gather their thoughts, consider their feelings, give an honest response, and be heard.  The strategy is to get participants thinking about how different ways of expressing their reactions impact differently on others around them. Then you’re having a discussion about the values and attitudes and cultural norms that surfaced in that unguarded moment of reaction, and that is a million times more useful than using your power as an educator to shame and silence someone.

The shame researcher Brene Brown has argued you can’t use shame to get someone to change their behaviour.  She defines shame as “the intensely painful feeling or experience of believing we are flawed and therefore unworthy of acceptance and belonging.”  Shame is affective and bodily but also social, concerned with the thought of our flaws being visible to others and them judging us. Understandably, in this light, intensified shame and anxiety about surveillance are two of the lifelong consequences of growing up online.

Imagine, now, that the Vulva Cupcakes discussion happens far, far away from the active facilitation of a sex education session: in the comments on an image visible to all on Facebook.  As it happens, you don’t have to imagine, because it did happen there, and the Director of Student Wellness Programs at Smith College in Northampton, Emily Nagoski Ph.D., helpfully reprinted it in a post on her personal blog about sexual health,’The Dirty Normal’.

In fact, Nagoski reprinted all the comments longer than “LOL”, complete with the commenters’ full names and links back to their Facebook profiles.

I’m not linking to the post or her site, for reasons I hope will become obvious.

Comments on the post are closed, so I expressed my concern to Nagoski via Twitter (@enagoski) where she said she was ‘giving CREDIT’ and disagreed that it violated any practice norm, whether from research, journalism or health education.

The ‘giving credit’ explanation is dishonest on its face: you don’t give people ‘credit’ for things you disagree with.

And I am staggered that someone can earn so many qualifications and yet remain so ignorant and unreflective about practice ethics. When you’re a sex educator, publishing the names and Facebook profile links for young people who say dumb shit about sex is perpetuating the kind of lifelong consequences we do our jobs to prevent.

Including the names adds nothing to the post — other than gender, which could easily be specified in brackets beside the comments.  It’s this lack of any other benefit that leaves me convinced Nagoski’s purpose is to name and shame.

This is not like quoting someone who’s placed themselves in public life, like a politician or another blogger; this is more like overhearing someone saying something stupid in a public place, and because you happen to know their name, you quote and name them on your blog.

When users of well-moderated online communities like Reddit.com post the stupid things others say on Facebook, there’s an incredibly clear norm against identifying them by name.  There is a sub-Reddit devoted entirely to the stupid stuff our friends and acquaintances say on Facebook: it’s called r/FacePalm (hurr hurr).  Here’s an image I picked at random.  Notice the redactions?

Here’s what the moderators say about identification:

  • Completely black out all personal info. This includes but is not limited to profile pictures, first and last names, links to other profiles, location data, and anything else that could be personally identifiable.
  • Do not post links to profiles or any other personal info. This will get you banned immediately.

Unfortunately there’s no moderator to appeal to, in this case, other than Nagoski herself, who has not proved receptive.  I can only call upon her to redact the names and Facebook profile links on her post.  If you agree with my concerns, you could perhaps (politely, please) add your voice to mine and express them on Twitter (@enagoski).

Doctors for the Family — but not evidence

If a doctor wants to abide by his or her conscience on the question of gay marriage, I’m fine with that.

If the same doctor claims to speak for the evidence on the health and social impacts of homosexuality, but instead speaks from his or her moral beliefs and distorts the evidence to do so, then I have a problem.

The Herald-Sun reports today that Prof Kuruvilla George, Victoria’s Deputy Chief Psychiatrist and Government-appointed member of the Victorian Equal Opportunity and Human Rights Commission, joined a list of signatories to a Senate Inquiry submission by “Doctors for the Family” opposing theMarriage Equality Amendment Bill 2010.

The submission was made after Prof George’s appointment to the Commission and makes his tenure there impossible;  lawful sexual activity is one of the attributes the Commission was created to protect.

Disagreeing about gay marriage isn’t the problem — it’s how the Doctors for “the” (sic) Family went about it.  They explicitly argue their case on health grounds, saying they were created to “highlight the health aspects of marriage and family and ensure a healthy future for our children.”  Their terms are medical, rather than moral.

“We submit that the evidence is clear that children who grow up in a family with a mother and father do better in all parameters than children without.”

The source they cite is a report by a Law professor from a study commissioned by the Australian Christian Lobby.  This is not medical evidence;  nor is it free of bias;  nor is it accurate about the current state of the evidence, which shows that children raised by same sex parents do as well as (and sometimes better than) children of opposite sex parents.

The submission goes on to refer to ominous “health consequences of that behaviour [i.e. homosexuality] for children”, but the footnote turns out to refer to HIV and syphilis infection.  These are vanishingly uncommon among children, and they are the consequences of epidemics of HIV and syphilis, not homosexuality.

These are not complicated moral questions: they’re matters of fact.  In giving health advice a doctor has a professional and legal duty to be informed and unbiased.  In claiming to speak as doctors and to offer advice about public and children’s health, these citizens have created that expectation and then signally failed to fulfil it.

The Australian Medical Association has firmly refuted the claims and the ABC is reporting the Minister for Mental Health, Mary Wooldridge, has asked Prof George for an immediate explanation. Attorney-General Robert Clark, who appointed Prof George to the Commission, needs to do the same.

Given his willingness to put scientifically unfounded personal beliefs ahead of the established evidence on homosexuality and same sex parentage, Prof George’s tenure as Deputy Chief Psychiatrist for Victoria and membership of the Commission are unsustainable and should be terminated.

The old digger

Jan Tully is someone I can honestly call a lifelong friend — she has known me since I was very little.  She is a grief counsellor and funeral celebrant, and a great friend to refugee families from Iraq.  Her father, Phill Rawlins, wrote this poem in 1958.  Apart from his obvious ear for metre, I can hear in it a familial sensitivity to loss and remembrance.  Thanks, Jan, for letting me reprint it here.

The Old Digger

When he’s marching through the City on some Anzac afternoon
Some would see a thing of pity in his thinned out old platoon.
Do they see what he is seeing, hear the tramp of ghostly feet?
No! They only hear the cheering and the bass drum’s solid beat.

But the Digger, when he’s marching pays small heed to local sounds,
When in memory he is roaming over far-off battle-grounds;
Takes small note of martial music or the shouting in the street
When his thoughts are with the fallen left in Anzac, Greece or Crete.

Some folks say that it’s all nonsense, to remember those long dead,
They’d rather watch the horses or a football match instead.
But he thinks he sees their faces when he’s marching with the band,
Seems as if he hears their laughing voices somewhere near at hand.

On this day above all others, seems he hears their ghostly feet,
When he’s marching with his brothers down some crowd-lined city street.
If he bears himself with courage and his eyes are damp with pride
Then you’ll know his ghostly comrades are marching by his side.

Yes, he’s faithful to his mem’ries though his eyesight may be dim,
Though his hair may fast be greying, still, it’s all the same to him.
So he trysts with living comrades, men whose friendship still is fine,
On the day the ghost battalions go marching to the shrine.

Do not wonder at his coming to the March on Anzac Day
If he’s living in the city or he’s many miles away.
For it’s hard to tell a civvy the things a Digger feels
When he thinks he sees old faces,
Hears the click of unseen heels.

Mark McCormack interviewed by Dean Beck & Lauren Rosewarne

I finished high school in 1999. Homophobia was rife, and being gay I took it all personally.  In first year uni I came out as gay, and went back to my old school to coach Year 9 debaters.  Now, 14-15yo teenage boys are pretty awful.  But they quickly figured out my sexuality — the Onion headline ‘Newly Out Gay Man Overdoes It’ could have been written about me — and the gay jokes ceased.  Every now and again they’d slip up, blush and say ‘Sorry’.  Gay was no longer some abstract anti-ideal; it had been personalised.

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