Introduction

In 1993, about 40,000 new HIV infections were occurring annually in the United States. Half of those newly infected were under 25 years old, and minority youth were being infected disproportionately. The HIV prevention strategies that had stabilized the epidemic among some groups weren’t working with young people.

As a result, the Centers for Disease Control and Prevention (CDC) launched the Prevention Marketing Initiative (PMI), a five-site demonstration project intended to show how coalition-based social marketing at the local level could address this trend. Here’s how the greater Sacramento area site organized their effort:

Step 1.1 Write a problem statement.

To develop a problem statement, a community-led coalition looked at available local data and found that:

• Teen pregnancy and rates of sexually transmitted infection (STI) were high among youth ages 15-19, especially in 15 Sacramento area zip codes.
• The 1995 California Youth Risk Behavior Survey (conducted by the California Department of Education) estimated that 45% of high school students were sexually active.
• AIDS diagnoses among the city’s young adults suggested that infection indeed was occurring during teen years.

The project came up with this problem statement: Youth ages 14-18 residing in 15 zip codes in the Sacramento area are at unacceptably high risk of HIV infection.

Step 1.2 List and map the causes of the health problem.

Literature reviews suggested a link between unsafe sex and drug and alcohol use, a decreased tendency to use condoms among teens with steady partners and among teens using other forms of contraception, and other epidemiological trends.

• Unprotected intercourse
• Substance use/abuse
• Lack of knowledge
• Intravenous drug use

Step 1.3 Identify potential audiences.

The interviewees felt that youth under 19 years of age were at risk, and that interventions should try to reach them while they were young.

Step 1.4 Identify models of behavior change and best practices.

The coalition tapped these resources:

• Summaries of relevant behavior theory (such as Theory of Reasoned Action and “stages of change” for condom use),
• Information about Project Action, a community mobilization and condom distribution campaign for teens in Portland and Seattle, and
• Summaries of three small-group interventions that CDC and outside experts had judged to have scientifically credible evidence of sexual risk behavior change.

This process continued through the next phases, as the coalition reviewed more information and returned to the literature to gain insight and validation of the local research findings and made their decisions.

Step 1.5 Form your strategy team.

Starting in 1994, the United Way-Sacramento Area was funded to assemble and coordinate a local volunteer coalition to be the community oversight and planning body for the project. The coalition comprised about 30 representatives from the AIDS, health, education, faith and civic arenas, as well as youth and parents. The United Way staff, technical advisors, and the national partners (the Academy for Educational Development, Porter/Novelli and the University of California-San Francisco Center for AIDS Prevention Studies) provided training, research support and technical assistance to guide the coalition through the planning steps.

Step 1.6 Conduct a SWOT analysis.

Strengths:

• The coalition offered a strong link to the community and an efficient way to assess what other interventions and priorities were in the community.

Weaknesses:

• Community norms would make it difficult to send messages about sex:
  • to very young teens
  • through schools
  • to substance-abusing youth
    
• PMI’s lead agency, the United Way:
  • wasn’t experienced in sexuality education or campaigns
  • had a very small program staff
  • would have to develop a new management structure or contract with other organizations to manage programs

Opportunities:

• The county and city regularly collected statistics on chlamydia and teen births.

Threats:

• There were concerns over the community’s reaction to condom promotion and distribution to teens.

Step 2.1 Define your research questions.

The coalition worked with the University of California-San Francisco Center for AIDS Prevention Studies to design a qualitative study to validate some of the findings from the gatekeeper interviews, build on literature on teens and sexuality, and assess the attitudes of local youth toward sexual health and behavior. The research also tried to gather some information on possible benefits to promote in a campaign, preferred channels, and credible sources of information. Specifically, the research sought to assess:

• knowledge, attitudes, values, beliefs, skills and practices concerning emerging sexuality, sexual practices, and safer sex behaviors (including condom use, abstinence and delay)
• risk factors associated with unsafe sex (including the influence of alcohol or drugs)
• sense of future, control of destiny, and what is considered “cool” or popular
• communication with partners and parents about sexuality and safer sex

Step 2.2 Develop a market research plan.

The project staff, in consultation with technical advisors and a coalition subcommittee with relevant expertise, developed a research plan and summarized the research design in a request for proposals (RFP). The winning bidder, the University of California-Davis, presented the research plan to its Human Subjects Review Committee to ensure that research was ethical and protected the participants.

The target groups for the formative research were teens ages 14 to 18 and parenting adults of 14- to 18-year-olds living in the 15 Sacramento area zip codes. The research was to be a qualitative exploration of the major determinants of risk and protective behaviors, looking at knowledge, attitudes, beliefs, skills and practices concerning emerging sexual behaviors. Parents were included to explore their influences on those topics and to gauge parental support for community-based HIV prevention.

The UC-San Francisco Center for AIDS Prevention Studies developed the interview and focus group guides.

Step 2.3 Conduct and analyze market research.

The project tried a number of recruitment strategies with varying degrees of success. Fliers were distributed by project staff in a few high schools and at a weekly summer street fair in downtown Sacramento that attracts large numbers of teens, and by community agencies to their clients. The street fair recruiting, community service agency referrals, and focus group participant referrals (snowball method) were quite successful.

In the summer of 1995, the UC-Davis HIV Prevention Studies Group conducted:

• 21 focus groups with 166 teen participants of mixed ethnicity, segmented by age, gender and sexual orientation,
• three parent focus groups, consisting of 22 parents,
• 30 individual interviews with teens, and
• 10 individual interviews with parents.

Step 2.4 Summarize research results.

The focus group research found that ethnically diverse teens had common interests and attitudes:

• Youth knew a lot about HIV but perceived little risk.
• Sexual activity and the opposite sex were very important.
• Sex often “just happened.”
• One consequence of unplanned sex was that condoms weren’t talked about and often weren’t used.
• Although youth knew where to get condoms and had tried them, few kept them handy.
• Youth cited drug and alcohol use as another reason for unplanned sex and not using condoms.

The market research offered much information on how teens viewed and used condoms:

• Although many in the target audience had already tried condoms, and may have used them sometimes, the audience saw many barriers to consistent use (such as a bad condom experience, the status of their relationship, other birth-control methods).
• The formative research, consistent with national data, suggested that incorrect condom use was an issue: complaints of leakage and slippage suggested that condoms were not being used correctly.
• Like the national literature, local research indicated that youth were not likely to use a condom with a steady partner, as a sign of trust or love. Yet the formative research showed that local teens considered a partner as “steady” after a short period of time and without clear risk assessment.
• Local research indicated that youth had unplanned sex for many reasons: sex with friends, denial of a possibility of having sex, or the influence of drugs or alcohol. In these instances, local research and national data suggested that youth were not likely to use condoms.

Research participants mentioned several benefits to condom use – benefits that were consistent with national research and program experience:

• Pregnancy prevention
• STI prevention
• HIV prevention
• Ability to act on distrust of a partner
• Feeling in control
• Worrying less
• Feeling self-respect
• A way to follow peer norms, which say that they should use condoms
• Ability to attain future goals

In addition to the focus group/interview research, staff compiled all the information they had collected from secondary sources into an “environmental profile” that included local, regional, and statewide data relevant to the target audience, such as:

• Demographic and lifestyle data
• Health statistics (such as HIV testing, STI, birth, and abortion rates)
• School enrollment rates
• Drug and juvenile justice data

The research report also included condom sales data for the city and listings of local youth development and youth-serving programs.

Step 3.1 Select your target audience segment(s).

In January 1996, the coalition’s “design team” met to narrow down the target audience and behaviors and make recommendations about intervention options.

Based on the formative research, the design team identified potential segments as:

• Youth who had unplanned/spontaneous sex
• Youth who had a steady partner
• Youth who used drugs or alcohol
• Young women who used other methods of birth control instead of condoms
• Youth who had tried condoms, but didn’t use them regularly
• Gender, ethnic and sexual orientation segments such as males, females, young men who had sex with men, African American young women

The focus group research indicated that teen urban culture was similar across ethnic segments, so the design team felt that most of the teen audiences could be addressed together. In addition, some of the audiences were considered too small to justify a program.

The design team refined the target audience to be sexually active youth ages 14 to 18 regardless of gender or ethnicity in 15 zip codes where high-risk behaviors were prevalent among youth. The zip codes included a number of minority and low socioeconomic communities. This segmentation would:

• include youth already exhibiting risky behaviors,
• ensure the most receptive and accessible audience,
• have service agency support available,
• include whites, Latinos and African Americans with high STI rates, and
• ensure that a range of gender and sexual identity subgroups (that is, heterosexual females, heterosexual males, young men who have sex with men but not gay-identified) were included.

The design team further segmented by behavior and decided to focus on youth who were currently sexually active, had tried condoms and probably used them inconsistently. National data, supported by the focus group research, indicated that many sexually active teens have tried condom at least once. In addition, the team felt that a program that targeted inconsistent condom users would address all the other behavioral segments it considered such as alcohol/drug use, partner relationship, use of other birth-control methods and having unplanned sex.

The coalition accepted the design team recommendation that the program’s target audience segment should be sexually active 14 to 18 year-olds living in the 15 zip codes, who use condoms inconsistently.

Step 3.2 Define current and desired behaviors for each audience segment.

The desired behavior for the audience began as “consistent condom use.” Using condoms consistently means using them correctly during every act of sexual intercourse and with every partner. To be clear, the desired behavior was refined to add “all partners” to include both steady and casual partners.

The team also decided to add the phrase “in all situations” to the desired behavior. The research had indicated that youth see particular situations (such as being under the influence of drugs or alcohol, or being in denial about the possibility of sex happening) as barriers to using condoms. Extending the behavioral objective to all situations could help develop specific messages to address unplanned sex and sex under the influence.

The team considered several factors—

• Risk
• Impact
• Behavioral Feasibility
• Resource Feasibility
• Political Feasibility

...to evaluate the target audience and its accompanying behavioral objective and decided that the audience and behavior met the criteria.

The final desired behavior was “use condoms correctly and consistently with all partners in all situations.”

Step 3.3 Describe the benefits you will offer.

The project used the following benefits in its communications: future/dreams, supportive social norms (being “cool”), and being in control and self-confident.

Step 3.4 Write your behavior change goal(s).

Sexually active youth ages 14 to 18 living in 15 Sacramento area zip codes who use condoms inconsistently will use condoms consistently and correctly with all partners and in all situations (such as unplanned sex).

The program staff also wrote an audience profile that included a summary of the background and formative research, the rationale for the audience and behavior decisions, and a summary of benefits and barriers to the behavior.

Step 3.5 Select the intervention(s) you will develop for your program.

The staff and technical advisors researched successful HIV programs to find activities that changed particular aspects of HIV-related behaviors. From this research, the staff proposed activities to the coalition, matching the activities to the key determinants that the program would address.

The barriers to consistent and correct condom use from the audience’s point of view were grouped by their respective determinants and were translated into needs from the program point of view:

Skills
Youth need:

• Condom-use skills for all situations
• Communication and negotiation skills for all partners and different situations

Self-efficacy
Youth need to feel confident:

• That they can use condoms with all partners in all situations
• About discussing and negotiating condom use with all partners in all situations

Peer and community norms
Norms should support:

• The use of condoms with all partners in all situations
• The discussion of sex and condom use between partners

Perceived risk
Youth need to believe:

• They are at risk for HIV and STIs
• They are at risk of pregnancy

Attitudes
Youth need positive attitudes about:

• The comfort and convenience of condoms
• Condom use with steady partners

Access to condoms
Youth need to know:

• Condoms are affordable
• Condoms are available
• Condoms are available at the right time

The coalition chose these interventions to address the determinants:

• Skills workshops (skills, self-efficacy, peer norms, perceived risk)
• Informational phone line (condom access, peer and community norms, attitudes, perceived risk)
• Mass media and print media (peer and community norms, attitudes)
• Condom distribution (condom access)

In addition, the coalition planned public relations efforts to continue community involvement and to respond to potential community concerns.

Step 3.6 Write the goal for each intervention.

Here are the goals for each intervention:

Skills workshops

• Increase awareness that teens are at risk for pregnancy/STIs/HIV
• Increase communication, negotiation and refusal skills to use with a sex partner
• Increase young people’s knowledge, skills and confidence in using condoms correctly
• Increase young people’s knowledge of where to get free or inexpensive condoms and promote the right to buy condoms

Informational phone line

• Increase awareness that teens are at risk for pregnancy/STIs/HIV
• Promote awareness of workshops (including time and locations) and the benefits of attending workshops
• Increase young people’s knowledge of where to get free or inexpensive condoms and promote the right to buy condoms

Mass media and print media

• Model the benefits of communication with a sex partner
• Promote awareness of workshops (including time and locations) and the benefits of attending workshops
• Increase awareness that teens are at risk for pregnancy/STIs/HIV
• Increase the belief that it is OK for sexually active teens to have, carry and use condoms

Condom distribution

• Increase young people’s knowledge of their right to buy condoms and where to get them, and to counter restrictive retailer policies
• Provide free condoms at local events and hangouts

Public relations

• Increase awareness that teens are at risk for pregnancy/STIs/HIV
• Target parents and adult influentials to increase the belief that communication skills are needed among teens and to encourage dialogue between parents and teens

Step 4.1 Select members and assign roles for your planning team.

The program staff did much of the planning of the interventions, and then presented the plans to the coalition for approval. In addition, the coalition had a youth advisory group that met monthly to provide advice, conduct formative and pretesting research, and create and review program materials.

Step 4.2 Write specific, measurable objectives for each intervention activity.

Skills workshops

• Hold four 8-hour workshops a month for 12 months
• By project end, 500 youth will have attended a Teen Stopping AIDS workshops
• By end of year 1, train 6 facilitators to lead youth workshops

Informational phone line

• 50 youth a month will call the information line

• Produce and air two radio spots on 3 urban stations for 12 months
• Print and distribute 50 posters a month to local businesses and youth organizations in the 15 zip codes
• Print and place 35 bus ads on local Sacramento buses for 4 months
• Print and distribute 200 palm cards a month to youth at community events and through local hangouts in the 15 zip codes
• 20% of local youth ages 14-18 will recall seeing or hearing a Teens Stopping AIDS ad

Condom distribution

• Produce and distribute 100 condom packs a month through local organizations and community events within the 15 zip codes
• Each youth participating in a youth workshop will distribute 3 condom packs to friends or peers
• Increase by 20% the number of outlets in the 15 zip codes offering free or low-cost condoms

Step 4.3 Write program plan, including timeline and budget, for each intervention.

• Transition plan. Outlined how the planning staff would prepare for program management and confirmed the roles of the coalition and its committees, including the youth advisory group. This plan identified new staff to be hired, job descriptions, timing for program preparations and other plans. Based on the transition plan, two new staffers were hired: a marketing specialist and a youth involvement specialist.
  
  
• Communication plan. Detailed all materials to be developed, including public relations and the information line. This plan outlined the goals of each type of communication and the types of messages to be supported. This plan was shared with the materials’ developers and the ad firm.
  
  
• Issues management plan. Outlined who would be used as spokespersons in case of public concern over the program activities or its objectives.
  
  
• Youth involvement plan. Revised to ensure continued youth involvement in the program to provide guidance and feedback.
  
  
• Public relations plan. Expanded the communication plan. The site staff also hired a public relations consultant to help them plan public relations activities in Sacramento such as desk side briefings with reporters about local teens and health.
  
  
• Annual workplan and budget. Submitted to CDC for contractual monitoring. This plan was much more detailed on the progress to be achieved by month and the associated costs. The Sacramento-area project was funded at $250,000- $300,000 a year for implementation.

Step 4.3.a Plan new or improved services.

Several separate plans were written for the program. There were service, product and communication elements (i.e., 4.3a, 4.3b, & 4.3d) in the intervention; they were addressed in an integrated fashion in the plans listed in Step 4.3.

Step 4.3.b Develop or adapt a product.

Several separate plans were written for the program. There were service, product and communication elements (i.e., 4.3a, 4.3b, & 4.3d) in the intervention; they were addressed in an integrated fashion in the plans listed in Step 4.3.

Step 4.3.c Plan a strategy for policy change.

Several separate plans were written for the program. There were service, product and communication elements (i.e., 4.3a, 4.3b, & 4.3d) in the intervention; they were addressed in an integrated fashion in the plans listed in Step 4.3.

Step 4.3.d Plan communication intervention/promotion activities.

Several separate plans were written for the program. There were service, product and communication elements (i.e., 4.3a, 4.3b, & 4.3d) in the intervention; they were addressed in an integrated fashion in the plans listed in Step 4.3.

Step 4.4 Pretest, pilot test, and revise as needed.

The project relied heavily on the youth advisory group and other youth for help develop and test products:

Program name. Volunteer graphic designers designed three logos each for four possible project names. Youth group members took these 12 graphics and surveyed 120 youth, mostly friends and classmates, and conducted mall intercept interviews. The name “Equal Respect” emerged as the most popular from this and subsequent pretests conducted by program staff. However, a pencil and paper survey in two public school classes showed that the name was more associated with a civil rights or women’s rights project, rather than an HIV prevention project. Eventually, another name—“Teens Stopping AIDS”—was selected.

Materials. Most of the printed materials, ads and the condom packs were developed by the youth advisory group and designed and printed with the help of a staff member who is a professional graphic designer. The youth group members went out to local hangouts or asked their friends for feedback on materials and concepts. The materials were revised and updated based on youth feedback.

Informational phone line. The staff contacted the local phone company and reserved the phone number 1-800-968-TEEN. The number was pretested with youth for recall.

Workshops. The workshop curriculum was selected from a list of evaluated HIV curriculum for youth, compiled by CDC. The curriculum Be Proud, Be Responsible was then adapted for the Sacramento area youth. In May 1997, the staff held a one-day pilot with youth volunteers to go through the revised curriculum and gain youth feedback on the activities. Their feedback was instrumental in finalizing the workshop.

Step 4.5 Summarize your program plan and review the factors that can affect it.

The program plan integrated the intervention activities so that they reinforced and supported one another. The mass media ads promoted positive social norms and attitudes while publicizing the information line. The information line and printed materials invited youth to attend the skills workshops. The workshops distributed condoms and encouraged participants to pass out condoms and information on the workshops to their friends. In addition, staff and youth volunteers manned booths at events and hangouts to pass out more materials and condoms to youth.

Here are some factors that did or could have affected the program:

• A partner’s conflicting goals. The United Way-Sacramento Area originally managed the planning phase, but it didn’t feel that managing the actual program was compatible with its goals. Another local organization, the Community Services Planning Council, took over management of the program in the implementation stage.
  
  
• Legal issues involving condoms. The staff wanted to make sure that youth buying and carrying condoms wouldn’t result in unintended consequences. The staff and volunteer lawyers studied California legal codes regarding condom buying and distribution for minors and found there is no age limit in California to purchase condoms.
  
  
• Restrictions on transit ads. The staff was concerned about sexual messages for youth being censored by the local transit authority. In September 1997, the staff and the program’s ad firm met with the transit authority to discuss limitations to bus-side advertising and reached an agreement on the word choices and graphics.

Step 4.6 Confirm plans with stakeholders.

The program staff stayed in close touch with the coalition, partners, and stakeholders throughout the program’s phases. Because the coalition was large and comprehensive, most of the stakeholders in the community were in the room during major decisions. Staff also met with youth serving agencies to learn about their access to the target audience, existing workshops, and to schedule times that would be convenient to hold the PMI workshops.

Staff also met with many youth serving professionals to learn their views on the need for and the political climate surrounding condom access. To assess the availability of condoms for youth, site staff visited local outlets that offered low-cost or free condoms to adolescents. One local record store sold condoms for less than a dollar.

In the September 1997 meeting with the local transit authority to discuss advertising style and copy an agreement was reached on word choices and graphics. One of the positive outcomes of the having a coalition-based program was that the word “condom” in the bus side ads did not raise any community concerns.

The staff also invited members of the Sacramento County Board of Supervisors to participate on a community review panel to approve the draft program materials. The panel included members from the Sacramento Alliance to Prevent AIDS (a group of program managers) and two county public health department staff. This step is required of HIV-AIDS-related materials to ensure that the program materials are not considered offensive by community standards.

Step 5.1 Identify what information needs to be collected.

CDC was responsible for the program evaluation and set these evaluation goals:

• understanding the process of using coalition-based social marketing at the community level,
• learning participant outcomes of a skills workshop that had been adapted from a “program that works,” and
• documenting outcomes of exposure to the overall program by the target audience.

CDC contracted with Battelle Memorial Institute, a research and development firm, to document the process used to coordinate the coalition and plan the program. Battelle listed relevant topics such as site management, coalition establishment, staff and volunteer perceptions, the coalition’s structure and workings, how decisions were made, how youth and community members were involved, and how technical assistance was provided.

CDC contracted the Academy for Educational Development (AED) to manage the evaluation of the skills workshops. AED worked with CDC to develop outcome measures based on the objectives in the curriculum.

CDC developed community-wide indicators for assessing the program’s overall impact, including such measures as recall of ads, norms and attitudes, behavioral intentions and reported condom use at last sex.

The program staff was responsible for reporting basic progress to CDC. In addition, the staff collected regular statistics for program monitoring, such as number of calls to the phone line, number of condoms distributed, number and frequency of ad placements, and number of youth attending the workshops.

Step 5.2 Select the key evaluation questions.

Step 5.3 Determine how the information will be gathered.

All survey instruments and questionnaires were submitted to a Human Subjects Review Board for an ethics and protection of participants review. In addition, because the project received federal funds, quantitative data collection plans were also submitted to the U. S. Office of Management and Budget (OMB) as required by the Paperwork Reduction Act.

• Telephone survey. Funded by CDC, Battelle measured the effect of the full campaign with an anonymous, cross-sectional, random sample telephone survey of 1,402 15- to 18-year-olds who lived in the 15 zip codes. The survey was conducted in five waves.
• Workshop questionnaires. AED worked with CDC to develop questionnaires that youth would complete before beginning the workshop, immediately after finishing the workshop, and four to six weeks after the workshop ended. The youth advisory group reviewed the questionnaires before the research began. Workshop participants were randomly assigned to an immediate intervention condition (that is, immediately scheduled to attend a workshop) or a wait-list control condition (in which they attended an unevaluated workshop after one-month follow-up data had been collected). Youth who participated in the evaluation received gift certificates to local music stores. The agencies that were funded to hold the workshops received additional funding to manage the extra logistics of the evaluation.
• Case study. Battelle documented the experience with an interview-based case study that highlighted lessons learned by individuals who had played various roles in PMI. Interviews were conducted after the planning and implementation phases. Battelle researchers visited the program twice in 1996 to review documents, observe a coalition meeting and a youth advisory group meeting, and to conduct interviews (a total of 20, including staff, youth and coalition members).
• Program monitoring tools. The staff put in place systems to track all data. The telephone company provided a monthly log of calls to the information line. The ad firm placing radio spots provided reports on the ads’ placement and frequency. The organizations that conducted workshops completed participation logs in order to be paid for their services. And the staff developed a workshop observation sheet to prompt comprehensive feedback and a curriculum checklist to monitor the thoroughness and fidelity to the curriculum.

Step 5.4 Develop a data analysis and reporting plan.

A local graduate student was hired part-time to manage the day-to-day logistics of evaluating the workshops. The manager ensured that the agencies and facilitators understood how the questionnaires were to be administered. The consultant coded the questionnaires and sent them to CDC for analysis.

CDC statisticians analyzed the telephone survey data and the workshop evaluation data using SAS statistical software. The intention was to publish the results in peer-reviewed academic journals after presenting them to the local coalition members.

In April 1997, CDC presented results from the baseline survey round to the coalition. Simple graphs of the results provided the coalition members and partner organizations with basic demographic, behavioral determinant, and sexual behavior data of local teens. These data served dual purposes – they informed the content of a second generation of radio ads in addition to serving as a baseline measure for the outcome evaluation. Because PMI was funded for only five years, final evaluation results were not available until after the completion of the intervention. (See SOC_EvalGuide.pdf)

Battelle wrote up the case study and distributed it to the staff and coalition members. The staff presented the program-monitoring data in monthly reports to CDC.

Step 6.1 Prepare for launch.

The coalition and staff were concerned that the community might react negatively to a campaign that promoted condom use among teens, even those already sexually active. After considerable discussion, they decided not to have a formal public launch of the program.

The staff finalized the design of materials. Six local youth posed for photographs used in handbills, posters and bus ads promoting the workshops. Staff collected price quotes for the production of print materials and collateral materials such as temporary tattoos, caps, T-shirts, mugs and dog tags all sporting the program’s logo and 800 number. Materials were printed in small amounts to allow for revision and flexibility. For example, handbills were printed with several designs to keep the look fresh and interesting.

After issuing an advertising RFP, the project selected a local firm to create and produce the radio spots and bus ads. The staff wrote a creative brief and the ad firm provided drafts for the coalition and the youth advisory group to review.

The project issued an RFP to community organizations to host and facilitate the workshops. The RFP was mailed in March 1997 to about 100 individuals and agencies. Nineteen attended a mandatory bidders’ conference and five agencies submitted proposals by the deadline. A proposal review committee made up of coalition, staff, and youth group members chose three agencies. Workshops began in June 1997 in 12 of the 15 target zip codes.

Also in March 1997, the youth group wrote the first draft of the telephone information line. First, the group developed an organizational chart for the information line. They selected topics that mirrored the workshop curriculum and included additional ones, such as HIV testing sites, resources and information on workshops and special events. A script was written for each topic using the curriculum modules and other material.

Step 6.2 Roll out and manage intervention components.

The workshops began in earnest after school let out in the summer of 1997. All the materials were in place to support the recruitment and program messages. Staff responsibilities clearly shifted with the launch. For example, management and oversight of the workshops became a full-time responsibility, including observing facilitation, managing costs and reimbursements, and providing supplies and condom packs for the participants.

The project funded a health educator to train the workshop facilitators and hired three local youth-serving agencies to recruit youth and hold workshops (about two a month). The daylong workshops are held in such settings as youth centers, housing projects, juvenile halls and alternative schools. The program’s collateral materials (caps, T-shirts, etc.) attracted youth to the workshops and provided encouragement and reward during the sessions.

By June 1997, the toll-free information line was fully operational, with eight teen-specific menu choices, five parent-specific menu choices, and one general greeting menu. Youth advisory group members recorded the teen messages.

The first radio ads, one for young women and one for young men, were pretested with local youth, finalized, and recorded. They ran in September and October 1997 on the three radio stations in the area that were popular with youth.

Posters, handbills, and ads in school newspapers took a phrase from the radio spots and added the faces of youth. Similar transit ads appeared on 35 bus sides in November, delayed because of production issues at the transit authority.

In April 1997, the local business newspaper ran an editorial about the health of young people in Sacramento. The project responded with a letter to the editor providing additional information about health issues related to sexual activity and encouraging businesses to get involved. The project didn’t conduct any additional public relations efforts.

The staff published a newsletter for coalition members, their organizations, and the local youth-serving organizations to keep partners informed of the progress of the project.

Step 6.3 Execute and manage the monitoring and evaluation plans.

The number of calls to the information line increased steadily in response to the radio spots (see graph).

During the second half of 1997, 500 youth participated in the workshops. The number was quite high during the summer, and recruitment became more difficult once school started. Feedback from workshop participants was very positive and insightful.

By 1998, the staff had established a system for monitoring the program. Their data are summarized in this table.

The workshop facilitators attended debriefings twice a year to discuss the successes and challenges they faced in implementing the workshops. The staff developed an inventory form for facilitators to track workshop materials and youth incentives and began attending several workshops a month to monitor performance.

A look at some key evaluation results:

Telephone survey:

• A year after the program was launched, more than 70 percent of the target audience was aware of it.
• Among teens who were already sexually active, exposure to the program was associated with a 25 percent increase in the odds of condom use at last intercourse with a main partner, as well as with condom carrying, positive condom use attitudes, norms and intentions to use condoms.
• The more parts of the program an adolescent had been exposed to, the more likely he or she was to report having used a condom.

Workshop evaluation:

• Compared with control youth, one month after the workshops, youth who attended the workshops scored significantly higher on measures of HIV knowledge, talking to friends about safer sex, condom use at last sex and condom carrying.
• Condom carrying was higher one month after the workshops. This variable was significantly correlated with condom use at last sex at baseline and at follow-up.
• There was no evidence that the workshops increased sexual activity.

Case study:

• The program increased local coalition members’ capacity to make data-based program decisions.
• There was no organized resistance to or negative publicity about the program.
• No other events occurred in the Sacramento area during the survey period that could account for the change in behavior reported in the community-wide survey.

The lack of community resistance to the straightforward risk reduction messages the project disseminated was attributed to having had respected community members’ input in planning, and to the coalition’s efforts to anticipate divisive issues and develop issues-management strategies in advance.

As per the dissemination plan, the staff presented the program and lessons learned at public health meetings such as the American Public Health Association annual conference. The evaluation results were published in academic journals.

Step 6.4 Modify intervention activities, as feedback indicates.

While many of the activities were found to be successful, they were continually updated and refined. Here are a few examples:

• During the first summer, one agency had major difficulties recruiting young people and decided not to continue the workshops. The following year, the staff recruited a new agency to host workshops.
  
• After a facilitator debriefing, the staff created cue cards to help facilitators and the peer helpers conduct the workshops.
  
• After the first summer, the staff revised the curriculum based on the experiences of facilitators and comments from the community review panel.
  
• In late 1997, the information line was updated with new information and fun music was added at the suggestion of the youth advisory group.
  
• As youth continued to report condom access problems, the staff met with the Sacramento County Department of Health and Human Services to develop a flier to create retailer awareness that there is no age limit on the purchase of condoms in California. Materials featured the Teens Stopping AIDS and the Sacramento County logos, along with contact phone numbers, and were distributed to stores that sold condoms.
  
• In February 1998, the staff decided to remove the bus-side ads because of printing mistakes made by the production company. The production company wasn’t paid for the work, and the resources were redirected to radio advertising. In April 1998, two new spots were recorded and aired on the three popular radio stations and a fourth popular station was added.

For more information on CDC’s Prevention Marketing Initiative (including references to published evaluation articles), visit http://www.cdc.gov/hiv/projects/pmi/index.htm.

List of resources:

• SOC_SacFocus.pdf
• SOC_SacProfile.pdf
• SOC_SacCom.pdf
• SOC_SacIssues.pdf
• SOC_SacYouth.pdf
• SOC_SacPR.pdf
• SOC_SacBudget.123
• SOC_EvalGuide.pdf