Examination of Witnesses (Questions 440-459)
MONDAY 18 NOVEMBER 2002
MR NICK
SPRINGHAM, MS
EVELYN ASANTE-MENSAH,
PROFESSOR MIKE
KELLY, MS
KAYE WELLINGS,
MR SIMON
BLAKE AND
MRS LINDSAY
ABBOTT
440. I stopped you just before you got on to
teenage pregnancy. Are there any messages in that? There will
probably be questions about this later. Why is the difference
so marked between this country and other European countries?
(Professor Kelly) One reflects of course the inequalities
of health dimension in this country in any event.
441. It is probably not all that different to
Germany.
(Professor Kelly) Compared to where the rates are
highest in the United States, we have got a very similar pattern
in terms of our population. In part it is historical, but the
best evidence we have got in terms of what would work is that
school-based education is good if it is linked to contraceptive
services. Ditto if it is community based and it is linked to contraceptive
services, that works well. Interventions which are linked to improving
self-esteem, vocational and inter-personal skills, and locating
sexual behaviour within the broader context are useful. If they
focus on improving contraceptive use, it is fairly simple stuff,
learning to use it effectively turns out to be quite useful. And
it should be long-term and tailored to the groups again and with
messages that are clear and accessible. I should also say that
the provider plays a very key role. Good teachers, people working
with students in an enthusiastic and interesting and participatory
way seem to work far better than taking a rather tentative or
tenuous approach. All of this is summarised in the documents available
from the HDA, which you can get off our web site quite soon.
Andy Burnham
442. Can I move on to the issue of mass media
advertising and direct a couple of questions to Miss Wellings.
Professor Kelly has just been talking about the need to have highly
targeted work and highly targeted messages to the groups we are
talking about. I was interested in the value of mass media advertising
and the use of fear of HIV in sexual health promotion generally.
Certainly the only mass media campaign I remember is the "iceberg"
campaign. It was a very memorable campaign. What are the key features
of campaigns in this country as opposed to continental Europe
and how effective do you think that campaign was, particularly
in terms of the mass media advertising campaign?
(Ms Wellings) It is interesting that you remember
the iceberg and tombstones campaign so vividly because there have
been many others since. The fact that it is so memorable partly
reflects the use of fear. It was more marked in this country than
it was in other countries, it has to be said. To some extent we
benefited in the long term from raising awareness at a relatively
early stage in the epidemic. The problem with a campaign like
that is it is quite difficult to follow up and it has consequences
that you would want to avoid if possible. One of the consequences
was that between Autumn 1986 and Spring 1987 when there was a
massive, intensive mass media activity on every front—commercial
media and government paid for media—was that there was a
surge of people attending clinics in this country for HIV testing
and there were letters to the BMJ from doctors saying,
"Please, if you are going to run these campaigns, will you
let us know in advance because we cannot cope." The clinics
just could not cope with demand. At the time at the then Health
Education Authority we were evaluating those campaigns, we were
monitoring the effect. When we drew graphs of that effect, we
were drawing peaks and troughs, so we were drawing peaks of public
awareness when there was a television spot on and then that was
followed by a relative lack of awareness.
443. Did any of the European countries follow
the same approach? Did they go for scare tactics?
(Ms Wellings) Not so much. There was an ad in the
Netherlands which had rows of candles blown out and they represented
deaths. In Italy there was quite a scary TV campaign using pink
lines that surrounded people who were infected, but in general
we used fear more than most. It did take us a while to get TV
advertising normalised to cope with the peaks and troughs. In
other countries there was much more use earlier of humour, and
the kinds of cartoon characters that can depict things like erect
penises that you cannot show on television.
444. The kind of things you see on Clive James?
(Ms Wellings) We could have learned something from
Wicked Willy, I suppose.
John Austin
445. You do not have to admit to watching Clive
James.
(Ms Wellings) Certainly the comic approach allows
you to tackle subjects that otherwise would be difficult.
Andy Burnham
446. You said there have been other national
campaigns. There were in this country other national media advertising
campaigns?
(Ms Wellings) There certainly were, there were several
of them, but I think it matters less that you cannot remember
them because at the time what those campaigns would have done
would have been to not only raise awareness in the general population
but would have kept the issue on the public agenda. They would
have shown policy makers and providers at a local level that their
efforts were legitimate, that the Government was spending money
on nationwide advertising because this issue was serious enough.
I do not think it particularly matters that you now cannot recall
specific ads. In fact, radio and press might be more effective
media to keep issues on the agenda rather than high profile television.
447. Because of the cost?
(Ms Wellings) Partly because of the cost but partly
because of the continuity.
Chairman: Might the fact that Mr Burnham
can remember a particular campaign, or two campaigns, have some
relevance to how old he might have been at the time?
Andy Burnham: Possibly 15 or 16.
Chairman
448. I am not sure who those campaigns were
targeted at.
(Ms Wellings) Those campaigns were targeted at all
ages who were sexually active. By design mass media campaigns
do reach everyone. In particular, in the National Survey of Sexual
Attitudes of Lifestyles, the proportion of young people who used
a condom at first intercourse was fairly steady over about three
decades up to the 1980s at about 40 per cent, during the latter
part of the 1980s it went up to 60 per cent, and it is currently
80 per cent. Certainly those campaigns, clearly together with
other aspects of prevention, did have an impact.
Mr Burns
449. Up to a point you have just answered me
because when you were answering Andy Burnham's question about
the gravestones and icebergs you gave a number of answers showing
the downside of that advertising and what I want to tease out
of you is what was the positive, given that at the time it was
an advertising campaign designed to draw the attention of the
population, or certain sections of the population, who were totally
or more or less unaware of the problem because to all intents
and purposes it was a new medical problem for most people. Surely
there must have been some positive outcomes from that advertising?
(Ms Wellings) I think that is absolutely right, there
were positive outcomes. They did use a high degree of fear and
fear works where (a) there are positive action points, so you
are not just saying there is something very scary in our midst,
otherwise if you do not provide the action points people can go
into ostrich position and deny what is going on, but (b) it has
to be seen to be real. The big problem at that time with HIV was
there was a very long lead time between knowledge that the infection
was in the population and symptoms being seen in those around
us. It was a particularly difficult campaign to execute. I think
fear certainly helped in raising awareness but it needs to be
followed up with good education and perhaps the level at which
that is delivered should be the community level. We had not really
got sex education up to scratch at the time.
Andy Burnham
450. Can I pick up the balance between national
advertising and local campaigns. In written evidence to us some
people have suggested that a worrying trend in recent years in
terms of sexual activity and behaviour is in some ways linked
to this move away from the big flagship national media advertising
to spending on advertising targeted locally. Would you see any
connection at all between those two things?
(Ms Wellings) Between increases in sexual activity
of the young and the absence of the campaigns on our screens?
451. Going towards a more local piecemeal approach.
(Ms Wellings) I think that the factors that explain
the sexual behaviour of the young are more complex. They are indeed
having sexual intercourse earlier, five years earlier, than they
did five decades ago but they are also settling later. They are
settling into generally monogamous relationships and have a good
roof over their heads and children later, so that whereas in the
1950s and 1960s 60 per cent of women had first intercourse with
somebody they were married to or engaged to be married to, now
fewer than one per cent do so. There is a longer period in which
young people are sexually active without settling down with one
partner. Whatever you put on the television screens, the fact
is that is a demographic trend which is probably here to stay.
I think that television certainly will raise people's awareness
of the need for prevention but it needs to be backed up with all
the other preventive efforts at community level, in schools, in
services and so on.
452. You touched on earlier the cost of mounting
such a campaign. Thinking about the difference between the 1980s
and the iceberg campaign and now the media is much more complicated,
you could get the national message over much easier in those days
when there were so many channels and the whole nation watched
the main channels, whereas now presumably it would cost quite
a bit. In an environment where there is pressure on resources
for access to GUM services, would that be the right way to spend
money, on a new national advertising campaign?
(Ms Wellings) Certainly in so far as it legitimates
action at a local level and insofar as it keeps the issue on the
public agenda, there is certainly something to be said for having
a media presence. I do not think the evidence suggests that it
needs to be a high profile tv advertising campaign of the kind
that we saw in 1986/87 because it will almost inevitably be followed
by a fallow period when we cannot afford to have television dealing
with the issue because there are other issues to balance resources.
The Teenage Pregnancy Strategy has been effectively using radio
and teenage magazine advertising and it has also been using a
website called RUThinking? We are in a different phase
of use of the media and those kinds of channels are proving very
effective.
453. One final question. In their evidence to
us I think the Department have indicated that they are soon to
launch a new national information campaign, whether television
advertising or not I am not sure but anyway it will be a national
campaign particularly highlighting the risks of unprotected sex
which covers the whole range of issues that we are concerned with:
teenage pregnancy, HIV, STIs. If that campaign is to be effective,
how do you think the message should be presented to the public?
You referred to campaigns using fear and humour. If you were doing
it, if you were the copywriter or whatever, what approach would
you take?
(Ms Wellings) I would do what the Department of Health
are doing, I would scan the evidence of all other campaigns. Certainly
in the Netherlands and in some of the Scandinavian countries they
have run some very, very effective simple slogan campaigns, "Unprotected
sex, no sex", the kind of slogans which encapsulate the fact
that if there is not a condom there is no sex. They are quite
lighthearted, they are quite simple, but they get the message
across. They do not use a lot of text with complex messages, they
leave that to the local level. I think wherever effective media
messages are conveyed almost invariably they are clever enough
to alert us to their presence without relying only on those ads
to get the message across. For example, if you are a head teacher
and you want to decide whether to put a condom machine in your
school, the fact that there is a government ad currently running
on condom use may just make you feel that your efforts may be
legitimate. If you run a garage and are wondering whether to put
condoms on the counter, the fact that the government is currently
running a condom campaign in magazines or on the radio might make
you feel that your efforts are legitimate. We must not forget
the legitimating effect of mass media campaigns.
454. And it should not be "Just say no",
it should be a message that—
(Ms Wellings) "Just say no" is very difficult.
We can say "Just say no" to drugs, we can say "Just
say no to heavy drinking and smoking", but the problem with
sex is that everybody sooner or later gets round to it, so it
is really "Just say when".
Jim Dowd
455. Some earlier than others.
(Ms Wellings) Some earlier than others, true, yes.
The thing about "Just say no" campaigns is that in my
view it would be much easier to promote readiness rather than
a negative message because we know that 50 per cent of young women
who have sex before the age of 16 regret that event having taken
place when it did, it was too early for them. Even if we made
it possible for that 50 per cent of under 16 year old women who
were sexually active to be able to have sex at the right time
for them, at a stroke we would increase the number of young women
who were having sex later. In my view, and looking at the evidence,
we do not need "Just say no" campaigns, we need campaigns
and we need more, we need community level initiatives which enable
young women, and it is usually I am afraid young women. The proportion
of young men who regret having sex before 16 was only an eighth.
It is a gender problem. To encourage those young women to be able
to resist pressure, either from boyfriend or media or peers would
create the same effect that you are trying to achieve with a "Just
say no" campaign.
John Austin
456. Can I just raise a question about the information
conveyed in the campaigns and the need for clear and unconfused
messages. In his question Andy Burnham referred to unprotected
sex and in the HDA paper there is a specific reference to unprotected
intercourse. In some of the discussions we have had, particularly
in relation to the sex industry, there is a popular mythology,
partly because of what was being said in the early days of HIV
that oral sex was safe sex, there is an assumption that it is
safe unprotected. Would you think that there has been an effective
information campaign that actually does highlight some of the
risks involved?
(Ms Wellings) I think there are two points there.
One is that in the population as a whole, and all of us in this
room probably do not talk about intercourse as we go about our
daily lives, we talk about sex, it is very difficult that whereas
in research you might want to talk about intercourse to be precise,
when you are educating the public the use of words that they are
able to relate to is going to be more effective. On the subject
of oral sex, there are people in this room who are better qualified
than I am to give the evidence but it is my understanding that
there is no decisive evidence that oral sex conveys a risk of
transmission of a magnitude to be very concerned about. There
was a Lancet article with five people who had contracted
HIV, as they said, through kissing but in actual fact we are always
dependent on the reports of people when they describe the sexual
behaviour that led to infection and it seems extremely unlikely
that there has been transmission of HIV by that method.
457. That is in relation to HIV, but in relation
to the alarming increase in other forms of STIs?
(Ms Wellings) In relation to herpes certainly oral
sex conveys a risk. I think you can convey that both in mass media
communication and in sex education by describing the activity,
you do not have to describe all activity as just "sex".
If you were talking about oral sex you would point out the risks
of some infections and not others, you would be precise and specific
about which risks were occasioned by particular activities. It
is necessary to be relatively frank.
Sandra Gidley
458. A question to Kaye Wellings, and Evelyn
Asante-Mensah might like to follow up. You mentioned when you
were trying to target particularly the Teenage Pregnancy Strategy
that you used a variety of media. It occurred to me that if you
were socially disadvantaged you might not have access to a PC
and you might not even have access to girls' magazines. Also,
from an ethnic point of view, a lot of the magazines that adverts
are placed in may be very white Anglo-Saxon in appearance. How
can you be sure that the messages are reaching a key audience
such as black and minority ethnic or even gay communities?
(Ms Wellings) We need to remember how small the proportion
of young women who have a child before 18 is. It is five per cent
so we are talking about one in twenty women. It may sound quite
a lot but in terms of mass media we are talking about five per
cent of the population who would be a mother before 18. That proportion
is highly concentrated in deprived areas and among particular
groups of the population. Here is where effort at the local level
is important and there is a plethora of effort at local level
now. Sure Start Plus is an extremely effective intervention, bringing
young women in contact with advisers at an early stage in pregnancy.
One of the things that the Department of Health has been doing
in concert with other departments is making an effort to positively
discriminate in favour of those from more deprived areas. I will
give one example of that not very clear statement. There is a
great resistance amongst young people who are from more deprived
areas and more deprived homes to terminate a pregnancy. We know
that. It is much more common to terminate a pregnancy if you are
from an upper socio-economic group and you are going on to higher
education. One of the things that is working in this strategy
is the provision of emergency contraception, because for some
reason there is not the same resistance and the same antipathy
to emergency contraception from these less well off, less advantaged
girls as there is to termination. Some of the things that are
being done within the scope of the strategy are specifically directed
at the less privileged, but it is not at the mass media level
you are going to see this.
(Ms Asante-Mensah) I totally agree. In terms of mass
media there have to be also local strategies for working with
different communities and also involving those different communities
in developing some of the messages they will take on board, be
it around teenage pregnancy or around STIs and HIV. If I can just
give an example. If we look at Sure Start Plus and under 18 conception,
we tend to leave out Muslim women who may have babies under 18
within a marriage because we assume that that is a positive choice
that they make. That may be a positive choice they have made but
it may not. It is about working within the different community
structures and infrastructures and how we support communities
to be part of developing messages in a way that is appropriate
to them. Magazines are not always necessarily the best way to
do it. We used peer education with young women, with young men,
with the older African community. We have found that one-off information
sessions do not do it. It is really about how do we sustain with
the community work that should go parallel with wider national
campaigns. I think national campaigns raise awareness but you
are in danger of missing out a whole range of people, whether
that is because the images do not reflect themselves or because
the language is not what they would normally use. It is very difficult
to target big national campaigns, but you have to have some way
of delivering locally as well those messages in much more appropriate
forms, I think.
Mr Burns
459. I am going to ask you a question which
you have partly answered but I still want to ask it because I
think you might have a bit more to say. There is research we have
seen, particularly in the Netherlands, that suggests that the
impact of an information campaign tends to recede fairly quickly
once it has stopped. Do you have any further advice as to how
safe sex messages can be promoted in a way that maintains a sustainable
rate, so that it does remain in people's minds and is not solely
dependent on either high profile, one-off campaigns or constant
campaigns?
(Ms Wellings) The country that comes to mind as providing
the best example of that is Switzerland. Switzerland had the most
effective Stop Aids campaign in which there was a deliberate attempt
to introduce synergy and sustainability and it was achieved by
using an image of a condom, a simple image, which initially in
the campaign was used as the O of "Stop Aids" and then
used as the O of "Okay" and the O of "Tonight"
and the moon above cities and the sun on holiday. That image of
the condom remained firmly in the Swiss mentality. In fact, one
of the evaluation techniques was to go to Geneva and Zurich airports
and ask foreign incomers what they thought it was. They said it
was the sun, the moon, an O, but every Swiss person said it was
the condom in the Stop Aids campaign. If we can get something
very simple, it is the "clunk click" equivalent in sexual
health, and something that we could use regularly so that we get
more effective use of the mass media. They certainly did in Switzerland.
Their rates of HIV were at the top of the ratings and they dropped.
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