Now what is it that you do?
Joseph Tucker’s parents back in western North Carolina understood why their son wanted to be a doctor. They got it when he decided to specialize in infectious diseases in far-off China. But now they aren’t quite sure what he’s doing, he said. Neither is the National Institutes of Health. But they like it.
“We actually have no idea what you’re doing,” one NIH grant reviewer told him on a recent grant application, “but we think this is absolutely fantastic, and we really hope it gets funded.”
Tucker, in Chapel Hill recently to touch base with his Carolina colleagues, chuckled at the recollection. “That was really a funny review.”
Tucker is director of UNC Project-China, a collaboration of Carolina faculty, students and trainees with Chinese partner organizations to conduct research on HIV, sexually transmitted diseases, maternal and child health, non-communicable diseases and other global health concerns.
Tucker started sexual health research in China 17 years ago. He is located in South China, in Guangzhou (formerly called Canton), the capital of Guangdong province. Guangzhou is centered in the Pearl River Delta, which is not only the largest urban area in the world in both size and population but also a hub for technology and entrepreneurship, similar to Silicon Valley.
That similarity made Tucker rethink how to promote sexual health in the region. “Why not use enterprise and innovation as a way to combat sexual health problems and to promote syphilis testing and HIV testing?” he thought.
In 2011, he co-founded Social Entrepreneurship for Sexual Health (SESH). The “sexual health” goal is to get more people tested for HIV and using condoms. It’s the “social entrepreneurship” part of the project that confuses people. Instead of using experts, consultants or agencies to produce the public service announcements, Tucker’s group organizes “creative contributory contests” open to the public.
This tapping into the collective public mind to get ideas is called crowdsourcing. And it seems to be working. A randomized control trial UNC Project-China did in 2014 to evaluate the crowdsourced video campaign versus one done by health marketing professionals showed promising results.
Slightly more (37 percent) participants in the study reported getting an HIV test for the first time after seeing the crowdsourced video than the professionally made one (35 percent). The crowdsourced campaign cost $14,926, compared to $26,358 for the health marketing group campaign.
Bottom-up, not top down
“An innovation challenge can produce videos just as effective as those made by companies and cost a lot less, about 40 percent less,” Tucker said. The contests also get communities more engaged in the health campaigns and reach a more diverse group of people.
Tucker’s team has used this unconventional method of spreading health messages in collaboration with the Guangdong Provincial Sexually Transmitted Disease Control Center and the World Health Organization.
Public health organizations face several challenges in this part of the world. Syphilis, HIV and other sexually transmitted diseases are on the rise in China, where there are 30 million more men than women. That ratio makes it much less likely for men and women to develop stable relationships or get married, Tucker said. Even the men who are married are also part of a culture that expects businessmen on company trips to drink and hire prostitutes, raising syphilis to an epidemic rate four to five times higher than in the United States.
But at least syphilis is curable. Not so for HIV/AIDS. Young gay men are especially susceptible but hard to reach because they remain severely closeted in China, some even covering their orientation with a wife and child, Tucker said.
How can a non-native ever hope to navigate those cultural subtleties?
That’s why Tucker turned to the grassroots experts – the public. In SESH’s contests, participants produce messages that are gentler, more thoughtful and more positive than typical disease prevention campaigns. The messages and images spring directly from the culture they are targeting.
In 2013, SESH launched a contest aimed at promoting HIV testing through one-minute videos. Publicly screened that December, the submissions were narrowed down to three finalists selected by a panel of judges from academic, public health, media and medicine backgrounds.
The winning entry, from Beijing, shows two men who meet, fall in love and test for HIV together. In the second-place video, from Chengdu, a man overcooks an egg and overfills a cup of juice, symbolizing that in breakfast as in HIV testing, it’s best to pay attention to what you’re doing before it’s too late. The third finalist, from Shanghai, shows a series of young men talking to the camera, with the message that – compared to cancers and heart disease – HIV is increasingly treatable, especially if you get tested early.
The most common way HIV is spread in the Pearl River Delta is unsafe sex; however, there are still many taboos about discussing safe sex, especially among youth.
SESH’s second contest, “Sex + Health,” focused on using still images to encourage young people to discuss sexual health.
The winning entry was a series of images of colorful safety pins representing people, with captions underneath.
“The idea of a person being a safety pin is what pulls in
the reader,” Tucker said. The captions are “like a little thoughtful dialogue” showing the complexity of what sex means to different people.
In English, something may be lost in translation, as in this caption: “In the crowded sea of people, we got to know each other, then we knew ourselves, and finally I knew myself. Sex is understanding.”
But “in Chinese, it’s not like an in-your-face campaign,” Tucker said. “It encourages reflection.”
The crowdsourced videos and images are not the least risqué, but they do touch on topics taboo in China, such as homosexuality. But the notoriously strict Chinese government hasn’t censored SESH so far.
The team’s preliminary data on contests promoting HIV testing and sexual health have been published in Sexually Transmitted Diseases and Clinical Infectious Diseases, leading to more SESH projects. The published article also includes a guide for organizations to implement their own contributory contests.
At SESH, a video contest to promote regular condom usage is in progress now and “syphilis is our next frontier for crowdsourcing,” Tucker said. SESH is also working with the World Health Organization to use crowdsourced videos to promote testing for hepatitis B and C.
The work Tucker is doing in China isn’t so mysterious after all. SESH’s crowdsourced campaigns use tried-and-true techniques like meeting with people in person and holding community events in addition to modern technology and today’s Internet culture.
But it has taken awhile for the medical establishment to understand this unconventional approach.
“It’s an unusual path,” Tucker admitted. “Our primary goal is promoting health, but in a way that’s sustainable over time. And we’re also coming up with something new and exciting and useful.”