| AIDS prevention through health promotion: Facing sensitive issues |
|PART 2 Approaching your audience: emotive appeal, tone, and setting of messages|
After the deaths from AIDS of a number of babies in 1984, the Australian Federal Government took the lead in the campaign against the disease. It successfully mobilized bipartisan support for its policies, ensuring a cooperative countrywide effort in the fight against AIDS. Federal coordination of the national response, among other things, permitted:
• the endorsement by State health ministers of a national health strategy for AIDS control;
• the development of a uniform policy on blood donation;
• the introduction of universal HIV antibody testing of donated blood and blood products;
• the establishment of various advisory committees with representatives from a wide range of disciplines and parties;
• the development of a national education strategy for AIDS.
These initiatives provided a solid foundation of public confidence in the Government's ability to respond appropriately to the AIDS threat and set the stage for a public campaign.
The national education strategy aimed to furnish education and support for community groups seen to be at high risk of HIV infection. However, the risk of spread of the virus to the heterosexual population, highlighted at the Second International Conference in Paris in June 1986, convinced government advisers of the need to extend the campaign to the wider public. At the beginning many Australians had seen AIDS as a disease confined to homosexuals. However, as the number of AIDS cases reached epidemic proportions, high-risk sexual behaviour and needle-sharing were seen to be widespread in the general community. Thus, when the Government embarked on a national education campaign, the principal objective was to make HIV/AIDS a matter of concern and relevance to all Australians. The mass media were chosen as the channel to disseminate the message quickly and persuasively.
The campaign was preceded by carefully managed promotion. In order to maximize its impact, great secrecy surrounded the content.
The campaign was launched dramatically in April 1987 as a week of prime-time television spots. It featured the traditional symbol of death, the Grim Reaper, as a scythe-carrying skeleton in medieval garb, who night after night bowled over human skittles in an underworld bowling alley. No one-baby, child, man, or woman-was spared the merciless assault.
It had been intended that the television spots should encourage people to seek further information, so in the following months additional advertisements were placed in newspapers, cinemas, and magazines and on the radio. The follow-up material emphasized prevention and contained comprehensive information about transmission, safer sex, and the antibody test, as well as contact numbers for further advice.
The campaign message was a blood-chilling one: the HIV/AIDS epidemic is advancing remorselessly, it is an inescapable part of our lives, we are all potentially at risk, prevention is the only cure. It was a message to make people sit up and pay attention. And they did. Almost immediately everyone seemed to be talking about AIDS, everyone had a view, the topic was discussed at every dinner party.
Unquestionably the campaign was enormously successful in creating awareness of AIDS. An unprecedented 97% of those surveyed had seen the Grim Reaper television spots. The campaign disseminated messages about AIDS transmission and prevention to millions of people in a very short period of time, and put AIDS in the forefront of the public mind.
After eight weeks a mid-campaign evaluation was undertaken to compare people's knowledge, attitudes, and behaviour with research data from before the campaign. The principal findings were that misconceptions about casual transmission were less prevalent and attitudes to preventive measures, such as use of condoms and the distribution of needles and syringes, more liberal.
People believed that the Grim Reaper had not only increased awareness and knowledge about AIDS but had also changed people's behaviour.
Many people felt that the campaign had prompted a desire for more information. It certainly created intense public debate. Articles about the relative risks of anal and vaginal intercourse as modes of transmission appeared daily. Discussion about heterosexual anal intercourse, attitudes to condoms, and bisexual husbands was explicit and very public.
By making AIDS a topic for public discussion the television campaign assisted in "the radical acceptance of the previously unacceptable". Programmes broadcast in 1988 about drug injectors, explicit billboard messages on safer sex, and young women promoting condoms on television would have been unthinkable before the campaign.
By opening for public examination subjects that the churches had traditionally seen as their concern, the campaign prodded them into becoming involved in AIDS programmes and in a range of subjects from condom use to care for the dying.
Sexually transmitted disease clinics reported a significant change in attitudes to condoms. In the commercial sex industry, brothel managers and, to a lesser extent, clients no longer actively discouraged condom use and many establishments supported sex workers who wanted to use them.
There had been unarticulated support for direct and explicit education prior to the Grim Reaper campaign, but after the campaign questions were raised about the lack of comprehensive school education on AIDS. The state departments of education were given a clear mandate to proceed with the inclusion of education on HIV/AIDS in the school system.
After the campaign, corporations and community groups of all kinds began to see a role for themselves in AIDS prevention and control, and a chance of funding. This resulted in a proliferation of organizations providing AIDS-related services and a bureaucracy to support them. The growth of this AIDS industry was accompanied by a wide variety of approaches and activities, and this diversity, coupled with the public debate and resultant increase in knowledge, has been a positive outcome of the campaign.
Less welcome results
The Government wanted all Australians to see AIDS as being of personal concern to them. However, the Grim Reaper campaign did more than that: for many people, it created unnecessary fear and, often, great anxiety about their past behaviour.
After the first television spots, laboratories performing HIV antibody tests were swamped with work. There were huge increases in the number of heterosexual men and women attending clinics and ringing telephone information services. These men and women did not, as the campaign had intended, want more information about AIDS. In fact, at the major AIDS clinic there was no increase in the number of requests for general information about symptoms, transmission, or safer sexual practices. Rather, people wanted to be tested, to allay the fear that their past behaviour had resulted in infection. The Grim Reaper campaign induced a large number of low-risk people to seek not information but reassurance. This obviously raises questions about the value of inundating services with unjustifiably frightened low-risk people.
In contrast to low-risk heterosexuals, there was no increase in the number of homosexual men or male and female prostitutes attending clinics. At the major AIDS clinic there was even a drop in the number of homosexual men attending for the first time.
The Government was insistent on providing follow-up information for the duration of the campaign and had enlarged state telephone information services to cope with inquiries. However, the early secrecy surrounding the content of the campaign meant that the services were unfamiliar with the material and unprepared for the overwhelming demand. In addition, supporting literature was not effectively distributed. If all the services-state, federal, governmental, nongovernmental-had been involved, education and counselling resources could have been better integrated with the campaign and fewer people would have been left with the feeling of an inadequate back-up.
Although the mid-campaign evaluation showed no increased prejudice against AIDS sufferers, the reality was somewhat different. The Anti-Discrimination Board recorded an increase in workplace discrimination and harassment and AIDS clinic staff reported an increased feeling of social ostracism among HIV-infected people.
Many AIDS educators, critical of the decision to use an advertising agency to produce health messages, reacted against the campaign's subliminal messages. Many groups had previously worked hard to promote the belief that AIDS is preventable and controllable and that everyone has the power to stop transmission of HIV infection by adopting particular forms of behaviour. The Grim Reaper campaign seemed to undermine that belief by portraying AIDS as indiscriminately and relentlessly eliminating its human victims. As no one had the power to resist, death was inescapable. The notion that people have the means to control their destiny was lost for the sake of a media advertising image. The promotion of the equation "sex = AIDS = death" undermined AIDS prevention work, and the abbreviation "sex = death" raised the spectre of the young generation growing up with inhibitory anxieties about sexual life.
The Government used the fear of death as a trigger to shock Australians out of their ignorance and apathy. Many believe that the exaggerated message had the opposite effect to that intended. Claims were made that the Grim Reaper campaign was merely a strategy to protect the gay community from being blamed for the epidemic. People eventually became bored with the flood of information about AIDS and withdrew from the debate. In some, the overkill merely reinforced their apathy and produced the familiar distancing effect.
At one level the Australian Grim Reaper campaign was an advertising triumph. It not only won an international advertising award, it was also successful in placing AIDS on the national agenda and creating a high level of personal awareness, public involvement, and debate about AIDS.
At another level it was less successful. Australians did not necessarily accept the concept that they were personally at risk. People were frightened, but fear did not necessarily prompt them to seek information about AIDS or about appropriate changes in behaviour. Those at high risk of AIDS did not seek AIDS services in great numbers, while those at low risk overwhelmed the testing facilities.
Australia has learnt some important lessons from the Grim Reaper campaign. Although the Government considers that it was successful, the campaign will not be repeated. The second phase of AIDS education is less intrusive, less dramatic; it involves targeting of specific groups, more consultation, more participation by the community, and a diversity of educational approaches.
The Grim Reaper campaign has confirmed that advertising and television spots, no matter how powerful, cannot replace community involvement and action.
Ballard, J. Politics of AIDS. Canberra Times, 14 August 1988.
Harcourt, C. et al. (1988) On the Grim Reaper Campaign. Medical journal of Australia, 149(3): 162-164.
Morlet, A. et al. (1988) The impact of the grim reaper national AIDS education campaign on the Albion Street (AIDS) centre with AIDS hotline. Medical journal of Australia, 148(6): 282-286.
Taylor, W. T. L. (1988) The grim reaper: the use of research in policy development and public education. Woden, Department of Community Services and Health.