Evaluation of the Acceptance Journeys Social Marketing Campaign to Reduce Homophobia

Abstract

Objectives. To evaluate the effectiveness of the Acceptance Journeys social marketing campaign to reduce homophobia in the Black community in Milwaukee, Wisconsin.

Methods. We assessed the campaign’s effectiveness using a rolling cross-sectional survey. Data were collected annually online between 2011 and 2015. Each year, a unique sample of Black and White adults, aged 30 years and older, were surveyed in the treatment city (Milwaukee) and in 2 comparison cities that did not have antihomophobia campaigns (St. Louis, MO, and Cleveland, OH; for total sample, n = 3592).

Results. Black self-identification and Milwaukee residence were significantly associated with exposure to the campaign, suggesting successful message targeting. The relationship between exposure and acceptance of gay men was significantly mediated through attitudes toward gay men, perceptions of community acceptance, and perceptions of the impact of stigma on gay men, but not through rejection of stereotypes. This model accounted for 39% of variance in acceptance.

Conclusions. This evidence suggests that the Acceptance Journeys model of social marketing may be a promising strategy for addressing homophobia in US Black communities.

For sexual minorities, homophobia is a key social determinant of health,^1,2 particularly with respect to HIV risk.³ Homophobia is the result of stigmatization—identification and labeling of differences on the basis of lesbian, gay, bisexual, or transgender (LGBT) sexual identity; linking undesirable beliefs or stereotypes to the characteristic; and marginalizing those associated with it.⁴ Marginalization takes a wide variety of forms, including prejudice, status loss, discrimination, and violence, and it creates contexts that can negatively affect the health of LGBT people.⁵

Manifestations of stigma create situations that lead to heightened HIV risk,^2,4 particularly for LGBT people of color who experience multilayered stigma associated with their intersecting racial and sexual identities.⁶ Experiences with homophobia have been linked to feelings of isolation and reduced self-esteem, which are associated with increased anxiety, suicidality, and depression.⁷ These factors are associated with HIV risk, particularly when HIV infection in the community is disproportionately high.^3,8

Homophobic experiences often occur within the context of family,⁹ religion,^10,11 schools, and other community settings.¹² Intervention efforts that seek to address homophobia in communities are promising strategies for promoting the health of LGBT people. Because homophobia affects HIV risk through multiple social pathways, communication programs targeting heterosexual audiences may be particularly fruitful avenues for intervention. When rooted in theory and formative research,¹³ communication may affect multiple levels in the social structure (e.g., individual, policy).¹⁴ In line with the Office of National AIDS Policy’s National HIV/AIDS Strategy, the Acceptance Journeys campaign aimed to reduce homophobia in the Black community in Milwaukee, Wisconsin.

In Wisconsin, nearly 1 in 3 Black men who have sex with men (MSM) are living with HIV.¹⁵ In 2009, the Wisconsin Division of Public Health and the Centers for Disease Control and Prevention (CDC) collaborated to investigate HIV diagnoses among young MSM in Milwaukee County. MSM who were 13 to 29 years old when diagnosed with HIV reported that they commonly experienced homophobia. They drew connections between experienced homophobia and their own negative feelings about their sexuality and discussed how it could result in HIV stigma, housing instability, exchanges of sex for housing and food, and a code of silence about homosexuality. In turn, these factors could increase HIV risk.^16,17 Acceptance Journeys was originated to address homophobia as an upstream determinant of HIV infection.¹⁸ Using principles of social marketing and communication theory,¹⁹ Acceptance Journeys aims to affect HIV risk by moving the community toward acceptance of LGBT people, mitigating experienced homophobia.

METHODS

The campaign’s design, implementation, and evaluation were a collaborative effort between Diverse & Resilient Inc, the University of Wisconsin, the Wisconsin Division of Public Health, the City of Milwaukee Health Department, and the CDC. Community readiness assessments guided the development of the overall campaign strategy. The message strategy was an annual, cyclical process of message design, concept testing, and evaluation, informed by focus groups.²⁰ The messaging was subtle in the early stages of the campaign and became increasingly explicit over time (Table 1).

TABLE 1—

Total and Targeted Impressions for Acceptance Journeys Billboard and Bus Station Ads: Milwaukee, WI, 2011–2015

Year	Tagline	Total Impressionsa	Targeted Impressionsb
2011	“Whose life could you change with love?”	40 502 422	7 217 435
2012	“I love my ____ just as (s)he is”	3 701 523	580 694
2013	“Who my ____ loves doesn’t change my love for her/him”	22 912 021	4 043 413
2014c	“My ____ shouldn’t be judged for who he loves” “Acceptance means no strings attached”	25 918 439	4 460 787
Total		93 034 405	16 302 329

Source. Data and media space were provided by ClearChannel Outdoor, Milwaukee, WI.

^aAll impression estimates include overrides (ads displayed beyond the paid time period). Estimates do not include impressions derived from placement on city buses.

^bTargeted impressions assess impressions among Blacks aged 18 years and older.

^cIn 2014, 2 complimentary taglines were launched. Impression data refers to both taglines.

The campaign brand alludes to faith journeys, which provide a rich analogy for journeys to acceptance.¹⁹ We sought to put words, faces, and names to the process that individuals go through in learning to love, accept, and appreciate difference. Acceptance Journeys highlights love and acceptance of LGBT people, the impact of stigma on the lives of LGBT people, and the impact of homophobia in the community.

Campaign materials included social media, print ads, a Web site, press releases, and story cards with strongly integrated branding. Messages were delivered through outdoor mass media (e.g., billboards), social media (e.g., Facebook), and Diverse & Resilient via story card presentations in community settings. Story cards are 5 × 5 stock cards with high-quality images of an LGBT person with a heterosexual friend, family member, pastor, or colleague with whom the LGBT person is connected. On the reverse, the ally describes her or his own pathway to acceptance (the Acceptance Journey). Story cards highlight themes that arose in focus groups through stories of growth and resilience. In total, the Diverse & Resilient developed 64 different story cards and included in 12 card packages.

Between 2011 and 2015, we distributed 5029 story card packs through campaign activities. Diverse & Resilient staff conducted more than 90 presentations through social service providers, community-based organizations, churches, classes, and school administration to build knowledge and capacity around LGBT health and wellness. Staff also participated in more than 25 community events, including block parties, leadership conferences, church events, health festivals, and celebrations.

Print media featured images used in story cards, branding, and a tagline (Table 1).¹⁹ We placed messages in numerous locations around Milwaukee, including newspapers, billboards, train and bus stations, and press kits. Billboards were strategically placed in locations that are densely populated by the Black community. Because individual city buses are not dedicated to specific routes, we were unable to geographically target or quantify impressions for bus ads. (“Impressions” are a standard metric in advertising to estimate the number of times an ad was viewed on the basis of traffic flows.) Similarly, we were unable to estimate impressions from secondary coverage, which included 2 segments featuring Acceptance Journeys on Black Nouveau (Milwaukee Public Television).

Evaluation

This study assesses the relationship between self-reported campaign exposure and acceptance of gay men. We hypothesized that Milwaukee residents would report more exposure to the Acceptance Journeys campaign relative to comparison city residents (hypothesis 1) and, within Milwaukee, Black respondents would report significantly more exposure to the campaign than White respondents (hypothesis 2).

We expected campaign messages to affect attitudes toward gay men by highlighting beliefs that work in support of acceptance, emphasizing unconditional love of family and friends and undermining beliefs about the need to reject gay loved ones because of their sexual identities.¹⁹ We expected that exposure to the campaign, which features community members and leaders, would directly and indirectly affect perceptions of community norms of acceptance.^21,22 Campaign messaging also highlighted discrimination faced by LGBT people. We expected that exposure to campaign messaging would raise awareness of the impact of homophobia on the lives of gay people. We also anticipated that exposure to images, which illustrate the varied ways in which LGBT people express their identities, would undermine stereotypes.²³ We hypothesized that any relationship between campaign exposure and acceptance would be mediated by attitudes (hypothesis 3a), normative perceptions (hypothesis 3b), acknowledgment of the effects of stigma on gay people (hypothesis 3c), and rejection of stereotypes (hypothesis 3d).

Participants and Procedures

We assessed the campaign’s effectiveness using a rolling cross-sectional survey. Data were collected annually (2011–2015) by Qualtrics online sampling company. Each year, Qualtrics surveyed a unique random sample of residents in Milwaukee (the treatment city) and in 2 comparison cities that did not have local antihomophobia campaigns: St. Louis, Missouri, and Cleveland, Ohio. We chose the comparison cities because of their similarity to Milwaukee with regard to the relative size of the Black population; distributions of gender, poverty, unemployment, and Black-owned firms; median household income²⁴; segregation ranking²⁵; and geography.

Eligible participants were aged 30 years or older, self-identified as Black or White, and were living in Milwaukee, St. Louis, or Cleveland. Only Black and White respondents were included in the study to allow for an adequate sample size for tests of interactions with race at each round of data collection. Participants consented online and were compensated (< $10), depending on their agreement with Qualtrics. Survey 1 data collection occurred between November 2010 and January 2011 (n = 792). Qualtrics conducted survey 2 in July 2012 (n = 414), survey 3 in March 2013 (n = 602), survey 4 in April 2014 (n = 907), and survey 5 in May 2015 (n = 880). Across surveys (n = 3592), participants were 50% Black and 50% White, were 67% female, and had an average income between $40 000 and $49 000. (Income was not included on survey 1, resulting in 805 missing cases for this variable. We conducted analyses on the full sample, which included survey 1 respondents, and on a restricted sample, which excluded survey 1. Results were similar in both samples.) The mean age of the sample was 50 years (SD = 12.82). Participants were approximately evenly distributed across Milwaukee (n = 1202), St. Louis (n = 1173), and Cleveland (n = 1220).

Measures

Controls.

Age was continuous. Gender and race were dichotomous. We divided annual income into 9 categories (≤ $19 999, $20 000–$29 999, $30 000–$39 999, $40 000–$49 999, $50 000–$59 999, $60 000–$69 999, $70 000–$79 999, $80 000–$89 999, and ≥ $90 000).

Exposure.

We assessed self-reported exposure to the campaign using images of ads to aid recall and brand recognition.^26,27 Participants were shown a series of images and asked if they had seen the corresponding campaign. We added Acceptance Journeys ads to the survey in the year in which the message was launched. Campaign images that were used in the survey were featured through various media channels, including story cards and print mass media (i.e., billboards). We coded exposure dichotomously.

Other campaign exposure.

To mask the purpose of the evaluation, the survey included filler ads, including images from national healthy living campaigns (Let’s Move!, 5 A Day), and national (Think B4 You Speak, It Gets Better, Call It Out) and local (Black Family and Friends, Gay Neighbor, We Are Part of You) antihomophobia campaigns; local campaigns were not run in comparison cities. Exposure to other antihomophobia campaigns was a dichotomous measure of any self-reported exposure to non–Acceptance Journeys antihomophobia campaigns.

Exposure channel.

Participants who reported Acceptance Journeys exposure completed a survey item indicating where they saw the campaign. Response options included the following: someone showed it to me, on a bus, at the airport, billboard, newspaper, Internet, and other.

Acceptance.

Evaluation outcomes discussed in this report are specific to gay men. We adapted the acceptance scale from previous research.²⁸ Each item on the scale represents a stage of acceptance, ranging from rejection (1) to appreciation (5) of gay men:“If a family member told me he was gay, I would no longer speak to him” (rejection); “It is important for me to avoid gay men” (avoidance); “I have no problem with gay men, but see no need for them to express their sexual orientation publicly” (tolerance); “In general, I believe it’s morally acceptable to be gay” (acceptance); “Gay men are of value to my community” (appreciation).

Stigma impact.

We measured the extent to which participants acknowledged that stigma has an impact on the lives of gay men by using the mean of 4 items: “My community’s views regarding homosexuality affect the lives of gay men” and “I think (name calling; physical violence; social rejection) has an impact on the lives of gay men in my community.” We coded response options (“strongly disagree” to “strongly agree”) such that higher numbers reflect more recognition of the impact of stigma.

Community norms.

Community norms were the mean of 5 items (3 for those with no religious affiliation), which asked participants to indicate their impression of how various communities (i.e., community at large, workplace, church, mosque or temple, family) feel about gay men. We coded response options for each group (“rejects” to “appreciates”) such that higher numbers reflect more acceptance.

Stereotype rejection.

The stereotype scale used the mean of 4 items²⁹: “Gay men are mentally ill,” “Gay men act like women,” “Gay men are likely to abuse or molest children,” and “Gay men were abused as children.” We coded scale items such that higher numbers reflect greater rejection of stereotypes.

Attitudes.

Attitudes toward gay men^30,31 was the sum of 3 items, coded so that higher numbers reflect more positive attitudes toward gay men: “Sex between two men is just plain wrong,” “I think gay men are disgusting,” and “Homosexuality is a natural expression of sexuality.”

Analysis

We tested bivariate relationships by using analysis of variance (ANOVA) for interval and continuous variables and χ² for categorical variables. We used logistic regression to test whether racial identification and city of residence were associated with Acceptance Journeys campaign exposure, controlling for other demographics.

Mediation analysis used the Process Macro for SPSS,³² model 4 (IBM, Somers, NY). The macro uses regression-based methods to test for mediation through multiple pathways simultaneously by estimating individual mediation paths, controlling for other mediators. The macro estimates the magnitude of associations for direct (unmediated) and indirect (mediated) relationships between variables in the model. Specifically, the macro calculates the direct relationships between the independent variable and the mediators (A paths), between the mediators and the outcome (B paths), and the indirect relationship between the independent variable and the outcome (A × B). Coefficients are unstandardized Β values. We determined the significance of pathways using a P < .05 cutoff.

RESULTS

There were no significant differences among respondents between cities by race (n = 3583; χ²₂ = 0.25; P = .89) or gender (n = 3591; χ²₂ = 0.86; P = .65). The average age was 51 years for Cleveland residents and 50 years for St. Louis and Milwaukee residents (F_2,3589 = 5.04; P < .05). The Cleveland sample reported significantly lower mean income (mean = 3.97; SD = 2.60) relative to St. Louis (mean = 4.40; SD = 2.63) and Milwaukee (mean = 4.29; SD = 2.73) (F_2,2787 = 6.72; P < .001); these mean incomes were not significantly different from each other, on the basis of posthoc comparisons with Bonferroni correction. There were no significant respondent differences between cities on the mediating variables (Table 2) using ANOVA.

TABLE 2—

Descriptive Statistics for Mediating Variables in the Relationship Between Exposure to Acceptance Journeys Social Marketing Campaign and Acceptance of Gays: Milwaukee, WI; Cleveland, OH; and St. Louis, MO; 2010–2015

			Mean (SD)
Mediator	Range	Reliability (α)	Milwaukee (n = 1201)	St. Louis (n = 1173)	Cleveland (n = 1220)	Sample Total (n = 3593)
Impact of stigma	1–5	0.87	3.07 (0.82)	3.05 (0.85)	3.04 (0.86)	3.05 (0.84)
Community norms	1–5	0.77	3.21 (0.72)	3.22 (0.72)	3.22 (0.77)	3.22 (0.74)
Attitudes	1–4	0.79	2.64 (0.92)	2.60 (0.92)	2.64 (0.90)	2.63 (0.92)
Stereotype rejection	1–4	0.88	3.22 (0.66)	3.21 (0.68)	3.26 (0.67)	3.23 (0.68)

Exposure

Thirty-eight percent of respondents reported exposure to the non–Acceptance Journeys antihomophobia campaigns, with no significant differences between cities (n = 3595; χ²₂ = 1.00; P = .61). Across cities, 20% of the sample reported having seen the Acceptance Journeys campaign. Bivariate analyses demonstrated that self-reported Acceptance Journeys exposure in Milwaukee (31%) was significantly higher than exposure in Cleveland (15%) and St. Louis (14%; n = 3595; χ²₂ = 136.43; P < .001). Respondents in Cleveland did not differ significantly from those in St. Louis.

Among Milwaukee residents who were exposed to Acceptance Journeys, the primary channels of exposure were billboard (44.6%), Internet (14.2%), newspaper (10.8%), and bus (10.2%). Few respondents were exposed at the airport (1.4%) or were shown an ad by someone else (0.6%), and 15.3% saw the campaign through unspecified channels. There were no significant respondent differences between comparison cities in channel of Acceptance Journeys exposure: Internet (39%), other (24%), billboard (13%), newspaper (11%), someone else showing it (4.1%), on a bus (3.8%), at the airport (0.9%).

Across cities, proportionally more Black respondents than White respondents reported Acceptance Journeys exposure (27.9% vs 11.1%; n = 3583; χ²₁ = 147.56; P < .001). Within Milwaukee, 45.9% of Black respondents reported exposure compared with 16% of White respondents (n = 1199; χ²₁ = 125.45; P < .001).

The logistic regression predicting Acceptance Journeys exposure by city of residence (hypothesis 1) and race (hypothesis 2), controlling for age, gender, and survey wave, demonstrated support for both hypotheses. Respondents in comparison cities were significantly less likely than Milwaukee residents to report Acceptance Journeys campaign exposure. Within Milwaukee, odds of Acceptance Journeys exposure were more than 4 times higher for Black respondents than for White respondents (Table 3).

TABLE 3—

Relationship Between Exposure to Acceptance Journeys Social Marketing Campaign and Demographic Variables of Respondents: Milwaukee, WI; Cleveland, OH; and St. Louis, MO; 2010–2015

	Full Sample (n = 3576)		Milwaukee Sample (n = 1197)
Variable	No.	AOR (95% CI)	No.	AOR (95% CI)
Constant		1.00		0.06
Age		0.99 (0.98, 1.00)		0.99 (0.98, 1.00)
Survey wave		1.60 (1.49, 1.71)		1.71 (1.54, 1.90)
Gender
Male	1220	1 (Ref)	404	1 (Ref)
Female	2371	0.86 (0.71, 1.04)	797	1.16 (0.86, 1.57)
Race
White	1794	1 (Ref)	606	1 (Ref)
Black	1789	3.08 (2.53, 3.73)	593	4.55 (3.37, 6.14)
Site
Milwaukee	1202	1 (Ref)		. . .
St. Louis	1173	0.33 (0.27, 0.42)		. . .
Cleveland	1220	0.35 (0.28, 0.44)		. . .

Note. AOR = adjusted odds ratio; CI = confidence interval. There were 5 survey waves. Age was continuous. The outcome was exposure to Acceptance Journeys campaign. For full sample, Nagelkerke R² = 0.21; for Milwaukee sample, Nagelkerke R² = 0.27.

Mediation

We hypothesized that any relationship between Acceptance Journeys exposure and acceptance would be mediated through psychosocial mechanisms targeted by the campaign. Results of the mediation analysis provided mixed support for hypothesis 3. Figure 1 illustrates the relationships between exposure and mediators, direct relationships between mediators and acceptance, and the remaining direct relationship between exposure and acceptance, controlling for mediators.

FIGURE 1—

Mediation of the Relationship Between Exposure to the Acceptance Journeys Social Marketing Campaign and Acceptance of Gays, Controlling for Demographics: Milwaukee, WI; Cleveland, OH; and St. Louis, MO; 2010–2015

Note: The sample size was n = 2773 (R² = .39; F_12,2760 = 145.53; P < .001).

**P < .01; ***P < .001.

Acceptance Journeys exposure had a statistically significant, positive association with perceptions of the impact of stigma, perceptions of community acceptance, and positive attitudes toward gay men, but not with rejection of stereotypes. Each mediator was positively and significantly associated with acceptance. The relationship between Acceptance Journeys exposure and acceptance was significantly mediated through perceptions of the impact of stigma (B = 0.01; P < .05), perceptions of community norms (B = 0.04; P < .001), and attitudes toward gay men (B = 0.04; P < .01). (Estimates are derived from the values of the A × B paths and reported by the macro.) The indirect effect of exposure through stereotype rejection was not significant (B = 0.00; P = .97). The total indirect relationship (the sum of A × B paths) between exposure and acceptance was significant (B = 0.09; P < .05). The remaining direct effect of campaign exposure was not significant (B = −0.05; P = .16). Findings provide support for 3 of 4 hypothesized mediation paths. This model accounts for a substantial portion of variance in acceptance (39%).

DISCUSSION

This study represents an important step for public health research and practice seeking to address homophobia in large metropolitan areas. Audience targeting was successful, and campaign exposure was positively associated with acceptance of gay men. That relationship is mediated through psychosocial factors that are consistent with the campaign focus on attitudes, community norms, and acknowledgment of the impact of stigma on gay people. However, campaign exposure was not associated with rejection of stereotypes.

Mean levels of stereotype rejection were high across cities. Thus, results may reflect ceiling effects for this variable. Alternatively, failure to affect stereotypes may reflect the deeply engrained nature of these representations and the singular focus of the analysis on Acceptance Journeys campaign exposure. Stereotypes about gay men are routinely perpetuated in the heteronormative cultural milieu, particularly through mainstream media. A single campaign may not be sufficiently ubiquitous to counter stereotypes. However, just as stereotypes are created and perpetuated over time, we anticipate that they may be changed with pervasive counterstereotypical portrayals. Acceptance Journeys did not move the needle on stereotypes in ways that are detectable in this analysis, but cumulative effects of various counterstereotypical portrayals are possible.

The campaign may generate effects in ways that are unaccounted for in this analysis.¹⁴ Exposure may have spurred interpersonal communication about acceptance of LGBT people in the community. Belief change that occurred as a result of discussion about the campaign, without direct exposure, would go undetected in this analysis. Future research should examine the effects of discussion generated by campaign efforts.

Limitations

This study’s findings should be considered in light of its limitations. These data are cross-sectional. Although we acknowledge that longitudinal data would have allowed claims of causality, budgetary constraints precluded it. To address this limitation, we triangulated several types of data to support our analysis. We demonstrated that the campaign was successful in targeting the Black Milwaukee community. We assessed exposure to other campaigns as an alternative explanation for the relationship and demonstrated that there were no differences between cities in exposure to other antihomophobia campaigns, but there were differences between cities in exposure to Acceptance Journeys. Results also demonstrate that those who saw the campaign were more accepting than those who did not, and that relationship is mediated through the psychosocial mechanisms that the campaign was designed to affect.

Respondents in the comparison cities reported Acceptance Journeys campaign exposure. This is likely a combination of actual exposure and misreporting. It is possible that residents of comparison cities were exposed to Acceptance Journeys, particularly online. Although Acceptance Journeys was not featured in the comparison cities, the campaign was active through social media. For example, one ad was shared by an LGBT news organization with the comment, “This parent should be a prototype!”³³; it received more than 10 000 likes, 600 shares, and 500 comments. Exposure in the comparison cities occurred primarily via online channels, but billboards were the primary mode of exposure in the treatment city. This evidence supports the possibility that many who reported exposure in the comparison cities may have seen Acceptance Journeys.

These data are based on a nonprobability sample of Midwestern residents. The generalizability of statistical estimates is thus limited. However, we anticipate that the processes that are supported by the study findings, which are consistent with theory-based hypotheses, may be relatively consistent across a variety of contexts.

Implications

Any effects of Acceptance Journeys are likely to be rooted in its hyperlocal nature. We engaged in a strategic process of message development research, design, and pilot testing that relied on deep collaboration with community partners and was responsive to insights and reactions shared by the community. Whereas the Milwaukee-specific contents of the campaign (i.e., images, stories) may not be appropriate for other cities to adopt, the process¹⁹ can be readily used to design other city-specific campaigns. For example, the Graduate School of Public Health at the University of Pittsburgh has developed and implemented an Acceptance Journeys campaign that is tailored to Pittsburgh and utilizes the processes outlined here and elsewhere.

Eliminating the disproportionate HIV burden carried by gay men of color will require multipronged³ efforts, including biomedical³⁴ and structural solutions,³⁵ individual risk reduction,²⁷ and changes in the social fabric. This study suggests that communication efforts may be effective at addressing homophobia and highlights a systematic process by which changes in the social fabric may be realized. When rooted in community collaboration and in strategic communication theory and principles and supported by evaluation research, Acceptance Journeys and other antihomophobia efforts can be effective at addressing community-level homophobia, an important component in the fight against HIV.