Ante La Duda, Pregunta: A Social Marketing Campaign to Improve Contraceptive Access during a Public Health Emergency

Abstract

During the 2016–2017 Zika virus outbreak, preventing unintended pregnancy was recognized as a primary strategy to reduce adverse Zika-related pregnancy and birth outcomes. To increase awareness and uptake of contraceptive services provided through the Zika Contraception Access Network (Z-CAN) in Puerto Rico, a multi-strategy campaign called Ante La Duda, Pregunta (ALDP) was developed. The principal aim was to increase awareness of Z-CAN services, which included same-day access to the full range of reversible contraceptives at no cost to women living in Puerto Rico who choose to delay or avoid pregnancy during the 2016–2017 Zika virus outbreak. Using diverse strategies, ALDP increased exposure to and engagement with the campaign in order to raise awareness of Z-CAN services in Puerto Rico. The ALDP social marketing campaign played an important role in the overall Z-CAN effort. Of all the strategies utilized, Facebook appears to have reached the most people. While the importance of a social marketing campaign communicating to raise awareness and create demand has long been known, through the ALDP campaign efforts, it was shown that an effective campaign, built on formative research, can be developed and implemented rapidly in an emergency response situation without compromising on content, quality, or reach.

Introduction

During the 2016–2017 Zika virus outbreak, Puerto Rico had the highest number of Zika virus infectious out of all states and territories in the United States (Lozier et al., 2016). Preventing unintended pregnancy was recognized as a primary strategy to reduce adverse Zika-related pregnancy and birth outcomes (Boulet et al., 2016; Oussayef et al., 2017). In response to the threat of severe brain abnormalities, including microcephaly, and eye defects caused by Zika infection during pregnancy (Olson et al., 2019), the Zika Contraception Access Network (Z-CAN) was established in Puerto Rico by the National Foundation for the Centers for Disease Control and Prevention, Inc. (CDC Foundation), with technical assistance from the Centers for Disease Control and Prevention and support of a diverse group of stakeholders and private donors (Lathrop et al., 2018; Romero et al., 2018). Z-CAN was a short-term program during an emergency response that provided client-centered contraceptive counseling through a network of trained healthcare providers and access to the full range of reversible contraceptive methods on the same day of service and at no cost to women living in Puerto Rico who chose to delay or avoid pregnancy during the Zika virus outbreak.

To increase awareness and uptake of Z-CAN services, a multi-strategy campaign was launched in November 2016 and remained active through the end of the Z-CAN efforts in September 2017. The campaign, “Ante La Duda, Pregunta” (ALDP), translated to “When in Doubt, Ask,” served as a call to action for women to ask their health-care providers questions about different contraceptive methods and specifically about Z-CAN services. Formative research (August et al., 2020), as well as relevant theoretical constructs, and tenets of social marketing were used to develop campaign strategies, identify communication channels, and design messages that would resonate with target audiences. The purpose of this paper is to describe the development, implementation, and process evaluation of the ALDP campaign.

Campaign background

The objectives of the ALDP campaign were to increase knowledge about the full range of reversible contraceptive methods, increase information-seeking behaviors related to contraception use among women of reproductive age in Puerto Rico, and increase awareness and access of Z-CAN services including the availability of same-day access to the full range of reversible contraceptive options at no cost to women living in Puerto Rico who chose to delay or avoid pregnancy. Due to the public health emergency, limited but critical formative research was conducted with women of reproductive age (18–49 years old) living in Puerto Rico (Table 2). Formative research was conducted between August and September 2016 to understand contraceptive decision-making in the context of the Zika outbreak in Puerto Rico (August et al., 2020). Data were collected via focus groups with the target audience (women of reproductive age) in multiple locations in Puerto Rico. Because men were often engaged in decisions regarding contraception, they were included in the formative research as well. The data collected provided important insights on motivators and drivers of contraceptive use among women of reproductive age in Puerto Rico, as well as culturally appropriate messaging, trusted sources of information, and dissemination channels to create an effective health communication and social marketing campaign. Formative research revealed that women were in need of answers to their clinical questions on contraceptive methods and that they experienced a variety of barriers when seeking contraception, such as access, availability of methods, and costs. Findings from the formative research led to the development of the campaign design and tone, as well as the messaging, which emphasized considerations that were most valued by participants, such as the availability of no-cost services through Z-CAN. In addition, the selection of relevant and appropriate tactics and channels were selected based on information provided by the participants. This helped ensure that the campaign was something the target audience could identify with and would be viewed as a source of trustworthy information. For example, women wanted to hear messages on contraceptive access from clinicians, so doctor and nurse personas were used in the campaign (August et al., 2020). ALDP’s target audience was women who chose to prevent unintended pregnancy during the Zika virus outbreak. Careful attention was taken to ensure that campaign materials and messaging resonated with women, regardless of socioeconomic status, educational level, or insurance coverage through the validation of messages with the target audience.

Table 2.

Rapid timeline for development and implementation of Ante La Duda, Pregunta.

Date	Activity
2016
May 23, 2016	Concept brief developed
June 20, 2016	Creative concepts developed (Round 1)
July 25, 2016	Creative concepts developed (Round 2)
August 8–10, 2016	Focus groups conducted in Puerto Rico to understand attitudes and perceived barriers to contraception access and use as well as acceptable messaging strategies about the availability of contraception through the Z-CAN Program
September 7, 2016	Creative concepts refined
September 12, 2016	Implementation plan developed
September 19–21, 2016	Focus groups conducted in Puerto Rico to collect information on preferred formats for messaging and dissemination channels; creative concepts for testing
October 6, 2016	Creative brief and branding map* developed
October 10, 2016	ALDP creative materials finalized and approved
October 14–21, 2016	ALDP collateral materials finalized
October 18, 2016	Communications planning meeting with key stakeholders in Puerto Rico
October 31, 2016	ALDP posters, postcards, brochures, and buttons printed and disseminated to Z-CAN clinics
November 4, 2016	ALDP Facebook page launched
November 9, 2016	Google digital advertising begun
November 14, 2016	ALDP media plan developed
December 2, 2016	ALDP campaign website (www.anteladudapregunta.org) launched with information on contraceptive methods and Z-CAN clinic finder
December 27, 2016	ALDP storyline videos launched on YouTube
2017
January 4, 2017	Z-CAN Physician FAQ videos launched on YouTube
January 7, 2017	Community engagement and outreach efforts began
January 15, 2017	YouTube advertising begun
January 17, 2017	Google Display Network advertising begun
January 19, 2017	Maxpoint digital advertising begun
January 30, 2017	Call-to-Action videos with Z-CAN physicians launched on YouTube
February 2017	ALDP materials reprinted & shipped (posters, postcards, brochures, buttons)
February 3, 2017	HCode digital advertising begun
March 13, 14, 20,2017	Recorded spots by show host (3/13), live mentions (3/14), PSAs (3/20), and live mentions began airing on local radio show #1
April 3, 4, 5, 2017	Recorded spots by show host (4/3), live mentions (4/5), and PSAs (4/4) began airing local radio show #2
April 2017	ALDP patient kits with brochures shipped to each clinic
May 2017	ALDP grocery bags printed
May 22, 2017	Outreach to paid influencers initiated
June 5, 2017	Z-CAN provider on-air interview with local radio station #2
August 20, 2017	Z-CAN patient and provider testimonial videos launched
September 23,2017	Last day patients seen/End of ALDP campaign

^*Branding map defines the vision, goals and strategy of the campaign.

Application of theoretical framework

The ALDP campaign was grounded in the Theory of Planned Behavior (TPB). Theoretical constructs from TPB guided the development of campaign messaging and the selection of dissemination channels. TPB suggests that intention is the most important determinant of behavior and that behavioral intent is influenced by three factors: behavioral beliefs, normative beliefs, and control beliefs (Ajzen, 1991). Behavioral beliefs refer to the degree to which the behavior will have the expected outcomes whether positive or negative (Ajzen, 1991). For ALDP, messaging showcased positive-expected outcomes through frequently asked questions (FAQ) videos, consumer storyline and doctor videos, and informative social media posts. Also, positive messaging was used on postcards, brochures, posters, and other collateral materials. Normative beliefs are the perception of societal pressures and norms that influence behavior (Ajzen, 1991). ALDP used visuals that showed women of different reproductive ages obtaining various contraceptive methods for free through Z-CAN. In addition, ALDP used Facebook to encourage women to share information about Z-CAN services with their friends and family. With the goal of also amplifying campaign messages, Puerto Rican influencers/bloggers were identified, engaged, and provided visuals and sample text that could be disseminated through their social media channels or blogs. Control beliefs are the degree to which a person perceives the ease or difficulty in performing a specific behavior (Ajzen, 1991). To engage women’s control believes, ALDP provided tools such as a clinic finder on the ALDP website to help women find a clinic convenient for them using their zip code; educational information, including information on each contraceptive method offered; and a script that women could use when making a Z-CAN appointment. TPB was helpful in translating findings from formative research into campaign messaging, creative materials, and ALDP tools, which gave control to and empowered women to access and use Z-CAN services.

Application of social marketing framework

ALDP applied recognized and critical social marketing principles to the planning, development, and implementation of the campaign, including the campaign messaging, materials, and strategy as well. Social marketing has been shown to be effective in a variety of public health interventions to influence action and encourage behavior change (Hornik, 2002; Stead et al., 2007). To be effective, social marketing efforts should be based on an understanding of the target audience’s own preferences and perception which ALDP addressed through the audience segmentation (dividing audience members up into smaller groups based on similarities, behaviors, and/or interests) and formative research process. In developing ALDP, we also focused on four key elements central to successful planning, development, and implementation of a marketing strategy: product, promotion, place, and price (known as the four Ps) (Andreasen, 1995). The campaign product included both augmented products (increased information-seeking behavior related to contraceptives and increased knowledge on the full range of reversible contraceptive methods) and an actual product (contraceptive method at no cost via Z-CAN services) (French et al., 2010; Lee & Kotler, 2015). Promotion was done through campaign messages (print, online, and on-air) that were developed based on formative research findings. Place referred to the placement of campaign messages on targeted channels reaching women of reproductive age. Channels were also selected based on findings of the formative research. The price of Z-CAN services was no cost to the women, and this was a central message in the campaign. However, given that 45.3% of women were not using a contraceptive method before Z-CAN (Lathrop et al., 2020), there was a social and/or emotional cost around selection of contraceptive method best fitting the woman’s needs and lifestyle. Also, a potential for physical cost of the utilization of the selected method. In addition to product, Table 1 summarizes consideration of promotion, place, and price within the ALDP campaign.

Table 1.

Marketing mix for Ante La Duda, Pregunta campaign.

Element of the four Ps	Definition	Application in ALDP
Product	The benefits associated with the behavior being promoted	Increased knowledge on the full range of contraceptive methods as well as increased contraceptive care seeking and utilization of contraception via Z-CAN services
Promotion	The types of communication that will be used to market the behavior	Campaign messages developed using formative research findings were applied to print materials, on-line, and on-air venues
Place	Where and when the desired behavior will be marketed	Placement of campaign messages on targeted channels to reach women of reproductive age in Puerto Rico where they live, work, play, and receive their health care services, including Facebook, internet, radio, community events, health centers/health care provider offices, and influential individuals in the community (as well as friends and family members)
Price	The financial, social, emotional, and/or physical cost exchanged for the benefit	Campaign messages underscored that Z-CAN services were provided at no cost. There was a social and/or emotional cost around selection of contraceptive method best fitting the woman’s needs and lifestyle (especially if first time using that type of contraceptive method). A potential physical cost is the utilization of the selected method.

Methods

Developing and implementing the ALDP campaign

To develop and implement the campaign, we identified a multicultural marketing agency with expertise in reaching Latino audiences and extensive experience developing behavior-change campaigns. The mix of media and communication channels reflected those most utilized by the target audience, based on the formative research findings. Social and digital media materials and strategies were prioritized and included the development of a campaign website and Facebook page with substantial digital resources, including storyline videos for consumers, videos tailored for providers, and digital advertisements. Community engagement events, print materials, and radio public service announcements (PSAs) were also utilized to ensure that messages would reach women in rural areas and those without digital access. Collectively, these campaign elements were intended to generate awareness of key messages while also demonstrating and encouraging individual action. Table 2 provides a timeline of the rapid development and implementation for the ALDP campaign.

Facebook page

The campaign’s first communication channel was a dedicated Facebook page, which provided an opportunity for two-way communication with the target audience. Women and men were able to share campaign messages and information with their friends and family members through the “tag” and “share” features on Facebook. This peer-to-peer promotion to their own social networks helped ALDP expand its reach and impact to the target population, women of reproductive age. During the implementation phase, posts were made to the ALDP Facebook page approximately three to four times per week. These posts were primarily educational and focused on sharing information on how to locate a Z-CAN clinic, the types of reversible contraceptive methods offered by Z-CAN, and campaign resources, including PSAs, storyline videos of local people featured in the campaign, and announcements of community engagement events. By reviewing the comments, as well as, pictures and resources shared, the research team was able to identify common questions/misperceptions/concerns on an ongoing basis that influenced and improved the relevance of the campaign’s messaging.

Campaign website

A campaign website (www.anteladudapregunta.org) was launched in December 2016 to further promote Z-CAN. In addition to information about Z-CAN services, the ALDP website featured educational information on the full range of contraceptive methods, frequently asked questions about contraception and Z-CAN, and a clinic locator tool to find Z-CAN clinics by zip code or city. The website also served as a central repository for campaign videos. The website was frequently promoted through messaging on the campaign’s Facebook page and on all campaign elements.

Digital videos and advertisements

Videos were created and used on the campaign’s Facebook page, as well as for digital advertisements. The videos reflected the campaign’s theme and utilized the two types of spokespersons recommended through the formative research - relatable women and knowledgeable and approachable physicians (August et al., 2020). All videos were produced in Spanish, and each ran between 30 and 60 seconds.

Six videos were recorded by two local Z-CAN physicians, one female and one male (three videos each). In these videos, the providers answered six FAQs and issued a call-to-action for the viewer to get more information about Z-CAN services. Each video was approximately 30–60 seconds.

To complement the physician videos, four storyline characters were created using local actresses (Figure 1). The characters - Isabel, Carla, Amanda, and Cecilia - represented women across various ages within the target audience - a college student selects an IUD (Isabel), a woman in her 20s who is in a committed relationship uses a birth control pill (Carla), a single business owner in her 30s selects the implant (Amanda), and a married mother of two daughters who is in her mid-30s uses a vaginal ring (Cecilia). Each of these one-minute videos consisted of background on who the characters are, why she was interested in a certain contraceptive method, how the contraceptive method fit her lifestyle, and what it meant for her family and future. From these storyline videos, two video PSAs were produced - one 30 s in length and another 60 s in length.

Figure 1.

Four storyline characters created for the ALDP campaign. From left to right: Amanda is a 30-year-old business woman who selects the implant; Carla is a 24-year-old wife who uses birth control pill; Isabel represented a 19-year-old college student who gets an IUD; and Cecilia is a 35-year-old wife with two kids and uses the vaginal ring.

Digital advertisements were purchased across Facebook, Google, and MaxPoint and featured the storyline videos produced for the campaign. For Facebook, both image and canvas ads featuring the stories were purchased and boosted for maximum reach. The Google buys consisted of display ads, as well as search ads to drive traffic to the ALDP website. MaxPoint is a digital network that is based on zip codes and allowed for geographically targeted display ads to ensure the campaign reached women across the island. The determination of where to target ads was based on campaign website visits and clinic searches conducted on the website. Ads were targeted to locations with fewer searches to encourage more engagement with the campaign in these areas.

Campaign materials

Campaign materials consisted of print materials, including two posters (in-clinic and community), a postcard, a campaign brochure, and various promotional items, including a button, reusable grocery bag, and a cell phone cardholder (Figure 2). In addition, a patient kit was produced and included a cosmetic bag with the ALDP logo with the campaign brochure, postcard, and condoms inside the bag. Print materials were distributed to Z-CAN clinics to display in waiting rooms and office areas and to Z-CAN partners to have available in their offices. Print materials and promotional items were distributed at various community engagement events, whereas the patient kits were given to patients who received services at a Z-CAN clinic.

Figure 2.

Examples of campaign print materials - a poster and the patient kit.

Community events

Participation in community events across Puerto Rico was critical to extend the reach and impact of the ALDP campaign messages. Examples of the events attended included health fairs, festivals, marathons/walks, presentations to community groups, and on-campus events at universities. These events were identified by a local health communication specialist who was in contact with universities, community organizations, and event planners of large, annual events such as various festivals and marathons/walks. These events gave women the opportunity to meet the local programmatic staff in Puerto Rico, learn more about Z-CAN, and get their questions answered in person.

Influencer engagement

With the goal of also amplifying campaign messages, Puerto Rican influencers/bloggers were identified and engaged. These influencers were selected based on their active level of engagement on social media and following/popularity with the campaign’s target audience. As a result, few of the influencers were health-based influencers. Each influencer was provided with language on the campaign and sample social media posts that could be disseminated through their social media channels or blogs. They were also provided with relevant campaign updates, highlights of campaign events, and additional campaign materials, including videos and imagery that could be used in their posts. Each influencer then helped extend the reach of the ALDP campaign by posting about the campaign and Z-CAN on their own social media handles and blogs, sharing materials with followers, and encouraging followers to visit the campaign website.

Evaluating the ALDP campaign

Ongoing evaluation of the ALDP campaign was important to measure that campaign strategies were implemented with fidelity, facilitating both reach and engagement through the use of appropriate and relevant channels. Evaluation questions and indicators were developed to assess the key strategies of the campaign (Table 3). Data were collected from a number of sources including web and social media platforms, internal staff, contractors, community partners, and other stakeholders. Each month, these data were aggregated and reviewed for accuracy, and internal evaluation reports were developed and shared with stakeholders on a monthly basis to inform campaign implementation and monitor campaign performance.

Table 3.

ALDP evaluation framework.

Evaluation Questions	Indicators
What were the trends on Facebook?	Number of ALDP Facebook posts Number of likes on ALDP Facebook page Number of engaged users on ALDP Facebook Page ALDP Facebook Page Reach
How did the Ante La Duda Pregunta website traffic vary over time?	Number of website views Number of unique visitors
How many people searched for Z-CAN clinics on the Ante La Duda Pregunta campaign website?	Number of clinic searches
What is the reach of the Ante La Duda Pregunta digital videos?	Number of digital video views
What is the reach of the Ante La Duda Pregunta digital media placements?	Number of impressions through digital media placements Number of clicks through digital media placements
How many campaign materials were distributed?	Number and types of campaign materials distributed
How many community engagement events supported the campaign?	Number of community events
How much were influencers engaged in the campaign?	Number of influencers engaged Number of impressions from blog and social media posts [Facebook, Twitter, and Instagram] by influencers

Results

The process evaluation results from the implementation of the campaign are presented in Table 4. From November 2016 to September 2017, ALDP’s Facebook page had 125 posts, 21,777 “likes,” and 333,004 engaged users (users who interact with a post by clicking anywhere on the post or story). The ALDP Facebook page reach (i.e., the number of people who received any content from the page) totaled 20,023,232 unique individuals. The ALDP website acquired 202,886 homepage views and 161,304 unique visitors between December 2016 to September 2017. Furthermore, there were 28,767 searches for Z-CAN clinics using the clinic locator tool on the ALDP website during this period.

Table 4.

Evaluation results of the ALDP campaign (November 2016 to September 2017).

Communication Strategy	Cumulative Number
ALDP Facebook Page
Posts	125
Likes	21,777
Engaged Users	333,004
Total Reach	20,023,232
ALDP Website
Home Page views	202,886
Unique visitors	161,304
Clinic Searches	28,767
ALDP Videos
Total Overall Clicks	155,179
Facebook Video Clicks	109,990
MaxPoint Video Clicks	1,112
H Code Video Clicks	22,432
YouTube	21,645
Total Completed Views	2,246,996
Facebook Video Views	214,274
MaxPoint Video Views	163,978
H Code Video Views	666,665
YouTube Views	1,202,079
ALDP Digital Advertisements (Facebook, MaxPoint, HCode, Google)
Number of impressions	124,540,476
Number of clicks	743,125
ALDP Materials Distributed
Postcards	35,824
Posters (in-clinic & community)	820
Brochures	3,579
Patient kits	201
Promotional items (grocery bags, buttons, cellphone cardholder)	27,398
ALDP Community Engagement Events
Number of events	33
ALDP Influencers
Number of influencers	23
Blog impressions	784,383
Twitter impressions	1,123,069
Facebook impressions	614,027
Instagram impressions	124,192

Digital advertisements were a large campaign strategy that was used across four channels (Facebook, MaxPoint, H Code (digital advertising platform to disseminate videos for Hispanic consumers), and Google). Collectively, the impressions (the number of times a digital advertisement was displayed) were 124,540,476 with 743,125 clicks. The computed click-through rate (CTR) (ratio of those who click on an advertisement to the number who saw the advertisement) for the campaign’s digital advertising was 0.60%. For video clicks, the Facebook video provided the most overall clicks with 109,990 in comparison to MaxPoint (1,112), H Code (22,432), and YouTube (21,645). With video views, YouTube provided the most views (1,202,079) in comparison to Facebook (212,274), MaxPoint (163,978), and H Code (666,665).

Print materials were a strategy used in various physical locations including Z-CAN clinics, local partners, and community engagement events. Postcards were the most distributed print item (n = 35,824), followed by 3,579 campaign brochures, and 820 combined posters. A total of 27,394 combined promotional items (including reusable bags, campaign buttons, and cellphone cardholders) were distributed to community members, as well as the nurses and doctors to promote the campaign. Additionally, 201 patient kits were provided to women who received Z-CAN services. ALDP was represented at 33 community engagement events.

Influencers were engaged to expand the promotion of ALDP and Z-CAN. Twenty-three local influencers were engaged and collectively resulted in 784,383 blog impressions, 1,123,069 Twitter impressions, 614,027 Facebook impressions, and 124,192 Instagram impressions.

Discussion

The ALDP campaign was able to apply evidence-based social marketing strategies informed by health communication theory to increase exposure to and engagement with the ALDP campaign in order to raise awareness of Z-CAN services in Puerto Rico. With the use of several channels and strategies, many women not only increased their access to knowledge on contraceptive methods but also became aware of the opportunities provided through Z-CAN to receive access to the full range of reversible contraception at no cost and on the same day of service across the island.

The ALDP campaign played an important role in the overall Z-CAN effort. Prior research demonstrated that the initial launch and implementation of the ALDP campaign produced a surge in clinic searches and Z-CAN visits, as measured by website and program data (average monthly initial visits increased by 2,135 visits (Romero et al., 2018). The process evaluation data estimated exposure to and engagement with the ALDP campaign through impressions. Impressions, which estimate the exposure to campaign strategies, are media data metrics recognized by the industry. The clicks and video views measure a higher level of engagement with the campaign compared to impressions. An example of this were the videos that were posted on the ALDP Facebook page. Viewers of these videos could have a deeper engagement by commenting, tagging their Facebook friends, and sharing the videos to others’ Facebook pages.

The multiple strategies implemented as part of the ALDP campaign brought a balance needed between the real-time reporting of data for quality assessment related to campaign planning and the analysis of measures of success for the overall campaign. As part of the quality assessment process, brief reports were developed on a weekly basis, allowing for timely programmatic adjustments and course corrections based on a quick feedback loop during the emergency response. For example, it was noted that the Facebook page was more active during a two-hour window of time in the evening. Based on that information, many posts, especially critical programmatic posts, were boosted as well as posted within that two-hour timeframe for maximum exposure. Another example of the use of process evaluation data as a monitoring tool was at approximately 6 months into campaign implementation an assessment was completed across the island to identify regions where the target population was searching for Z-CAN clinics and services. In response to regions with fewer clinic searches, communication efforts were increased through targeted digital advertisements and increased community engagement events. Overall, our results support current research, that communication campaigns using multiple strategies, including media, social networks, and targeted development of creative materials, have the potential to increase the reach and adoptions of contraceptive services (Eisenberg et al., 2012). Our results are also aligned with other research showing that social media is not just an effective channel but also culturally appropriate to reach young women with contraceptive knowledge (Sundstrom et al., 2016).

Of all the strategies utilized, Facebook appears to have reached the most people. The ALDP Facebook metrics indicated a total of 20,023,232 unique individuals reached from November 2016 to September 2017 when the Facebook page was actively posting and responding to comments. Facebook provided a relevant platform that allowed for the ability to quickly post with no costs involved. It also allowed for flexibility to address multiple topics with video and images and no limit on content. From previous formative research (August et al., 2020), we knew that Facebook was a highly used channel among our target audience. It quickly developed to be a useful vehicle to receive user comments and engage in dialog with members of our target audience. Comments helped identify common questions, misperceptions, and concerns and prompted the development of additional and relevant campaign messaging on a weekly basis. In addition, posts on Facebook helped drive the most traffic to the ALDP website and clinic searches. During periods of heavy campaign activity on this channel, increases in Z-CAN clinic searches were noted.

Digital ads placed across four different platforms - Facebook, MaxPoint, H Code, and Google-turned out to be another effective channel for campaign dissemination. The impressions were high (124,540,476) and the CTR for ALDP was above industry standards for other health and medical campaigns (0.60%). The combination of the four platforms also allowed us to better target our audience based on different consumer interests and use geo-targeting. Ads could point users on different platforms to the closest Z-CAN provider available based on their location when accessing an ad or a video. The use of influencers proved useful in reaching the target audience since their social media presence and networks considerably amplified our messages - especially on Twitter which was a channel that the campaign originally did not use. The print materials were distributed at the community engagement events. In terms of impact and reach, these were the least preferred but while not extensively distributed, they had value and were effective in communicating information in areas where access to the internet and digital assets were minimal. Print materials combined with the promotional items were more popular.

While ALDP was a successful campaign, there were some limitations. The campaign was created during an emergency response so there were time constraints on the launch and execution of the campaign. The ALDP campaign ended shortly after the Z-CAN services stopped. The generalizability of this study is limited due to the formative research and implementation being based on the context around contraceptives and access in Puerto Rico. The primary strategies of the ALDP campaign were digital (Facebook, website, video PSAs, and digital advertisements), which meant that women who were not on social media or online often did not have as many opportunities to exposure of the campaign. Finally, data were not available from the radio advertisements, radio spots, PSAs, and live mentions from the Puerto Rican radio partners and so the reach of these approaches cannot be determined.

While the importance of a health campaigns to raise awareness and create demand has long been known, through ALDP, it was shown that an effective campaign, built on formative research, can be developed and implemented rapidly in an emergency response situation without compromising on content, quality, or reach. These findings may also inform initiatives in other US territories or the continental US that focus on implementing communication strategies to educate women of reproductive age on contraceptive methods and inform them about programs available to them that increases their access to contraceptive methods.

Conclusion

The ALDP campaign increased exposure to and engagement with the campaign in order to raise awareness of Z-CAN services in Puerto Rico using Facebook, the website, videos, radio, digital advertisements, print materials, influencer engagement, and community engagement events. Due to the nature of an emergency response, the development and implementation of the ALDP campaign occurred in a very short timeframe; however, the ALDP campaign was successful in establishing a comprehensive-branded health campaign.