Sextagram: Evaluating an Italian Instagram-Based Health Campaign Against AIDS

Abstract

The use of social media for disseminating health information to adolescents and young adults has garnered significant ttention, showing promising results. Younger audiences increasingly prefer social media and mobile aggregators for their informative needs, considering these platforms reliable sources, particularly for sexual health and general health topics. This paper discusses the findings of a two-year project conducted in Italy—in collaboration with a group of non-profit organizations—funded by The Ministry of Health, intending to explore social media-based health communication strategies aimed at prevention for individuals aged 18 to 25. The objective was to leverage Instagram to engage young people, enhancing awareness about the risks of STIs and HIV/AIDS and promoting preventive behaviors. By analyzing two contrasting perspectives on health communication methods and the results in terms of engagement metrics and user feedback in the chosen profile, the study provides insights into social approaches for health communication and social representations of sexuality in the digital age, demonstrating risks and advantages of the use of platforms to influence health knowledge among young audiences.

1. Introduction

Health communication plays a crucial role in disease prevention and the promotion of public health. Effective strategies can significantly influence health behaviors and outcomes. According to the World Health Organization [1], effective health communication can improve health literacy, facilitate behavior change, and support public health campaigns. However, achieving efficacy in health communication is complex and multifaceted. The literature tells us that there are some main components of effective health communication. One question concerns message design and delivery: messages must be clear, culturally relevant, and tailored to the target audience. For example, Kreuter and McClure [2] emphasized the importance of audience segmentation and personalized communication in improving message effectiveness. For instance, adapting the content and visualization to the platforms’ affordances and their different audiences in social media communication is crucial. A second aspect highlights the importance of an integrated strategy of multiple communication channels: using various channels (e.g., social media, mass media, interpersonal communication) enhances the reach and impact of health messages. Noar et al. [3] found that multi-channel campaigns are more effective in changing health behaviors than single-channel efforts. We can also find interesting reflections on the theoretical frameworks: applying behavioral theories such as the Health Belief Model, Social Cognitive Theory, and the Theory of Planned Behavior provides a structured approach to developing and evaluating health communication interventions. Glanz and Bishop [4] highlighted the significance of these theories in predicting and explaining health behaviors.

More critical works raise questions about equity, social justice, participation, and cultural sensitivity. Equity: A significant challenge remains to ensure that health messages reach and resonate with diverse populations, including those with low health literacy and marginalized communities [5]. Therefore, we should consider the socio-economic determinants of health and ensure that health communication practices do not reinforce existing inequalities [6]. Social justice: advocating for equitable access to health information and resources, particularly for marginalized communities, and analyzing who holds power in health communication and how this affects the dissemination and reception of health information [6,7,8]. Participation and cultural sensitivity: Recognizing and integrating diverse cultural perspectives in health messaging and involving communities in creating health messages [9,10,11].

Moreover, some studies show that the best health communication practices can help to enhance awareness and knowledge. We can evoke, for example, Dubé et al. [12], who observe that health communication has played a crucial role in increasing vaccination rates since targeted messages and social marketing strategies have effectively addressed vaccine hesitancy. Communication strategies promoting healthy lifestyles and early screening have shown positive outcomes in preventing and managing chronic diseases like diabetes and cardiovascular diseases [13]. Finally, The COVID-19 pandemic highlighted the importance of consistent messaging from trusted sources to enhance public compliance with preventive measures [14].

Despite these positive outcomes, several challenges and controversies persist in social health communication for prevention, above all, the necessity of continuous evaluation and adaptation of communication strategies to respond to evolving public health needs and technological advancements [15], as well as methods to verify its efficacy. In a review of eHealth communication modes in preventing sexually transmitted infections, Nourimand et al. [16] found substantial heterogeneity in reporting objective indicators of STIs (sexually transmitted infections) prevention. In general, very few health communication campaigns have successfully identified behavioral change indicators in their strategy, as social marketing studies suggest [17,18,19], except in some specific projects aimed at single actions in communities or schools [20,21].

Recently, the use of social media for health information addressed to adolescents and young audiences has received more attention and promises remarkable results in terms of engagement [21,22,23]. Although younger populations increasingly prefer social media sources and mobile aggregators to access information [24,25], there is insufficient evidence on the internal stratification of their internet practices and information-seeking behaviors [26,27]. Another complex issue that should be considered—but falls outside the scope of this article—is how social media influence agenda-setting, contribute to the framing of social issues and play a role in selecting relevant information [24].

In the context of the StIngS project1, central to the present case study, the fundamental premise was that a considerable portion of young people aged 18–25 are not inherently interested in health information. However, their engagement can be increased by leveraging their preferred languages and communication channels and addressing topics that resonate more closely with their interests, such as sexuality. Consequently, the project proposed that a communication strategy using social media platforms like Instagram could be effective. This strategy involved creating a page dedicated to various aspects of sexuality, presented with a touch of irony, while simultaneously promoting prevention topics such as condom use, PrEP, the necessity of testing, and other issues related to HIV/AIDS and sexually transmitted infections (STIs). However, their engagement can be increased by leveraging their preferred languages and communication channels and addressing topics that resonate more closely with their interests, such as sexuality. Consequently, the project proposed that a communication strategy using social media platforms like Instagram could be effective. This strategy involved creating a page dedicated to various aspects of sexuality, presented with a touch of irony, while simultaneously promoting prevention topics such as condom use, PrEP, the necessity of testing, and other issues related to HIV/AIDS and sexually transmitted infections (STIs).

The primary objective was to enhance awareness of the risks associated with STIs and HIV/AIDS since data regarding Italy [28] indicate a low usage of seropositive testing. Additionally, in 2022, despite a slight decrease from 2015, 58% of the 403 new diagnoses were of late-stage AIDS, with approximately 84% of these cases resulting from sexual intercourse [28]. This data suggests a significant information gap among the general population, particularly young heterosexual individuals, regarding the persistence and transmission of the virus. Furthermore, journalistic coverage of HIV/AIDS has progressively declined and shifted focus. For instance, research has shown how, according to the dominant journalistic narrative, the epidemic’s epicenter is no longer the West but predominantly Africa and the Global South [29,30].

Moreover, although the stigma surrounding HIV-positive individuals persists, it has broadened beyond the male LGTBQI+ community [31]. New archetypes such as the infector, the survivor, and the victim have emerged, framing HIV/AIDS as a radical “otherness” [32]. In this context, the heterosexual population and women, both heterosexual and homosexual, remain on the periphery of the discourse, except in extraordinary or “deviant” circumstances [29,30].

2. Methods and Controversies: A Gripping Debate on Health Communication Methodologies

The authors served as scientific advisors for a participatory project presented to the Italian Ministry of Health, representing seven organizations engaged in AIDS issues through CNCA, a national non-profit federation. During the first six months of our two-year project, we conducted: (a) a systematic literature review of papers concerning the type of visibility of the HIV/AIDS topic, using the first 100 titles emerging from ProQuest; (b) a benchmarking analysis of existing similar profiles in Italian on Instagram; (c) a little survey to a convenience sample of 100 young university students; (d) 30 in-depth interviews to a group of potential ambassadors. Based on the findings of this background analysis2, we designed a participatory method to create and manage an Instagram profile for 12 months as a first experiment to provide information in an entertaining key that young people could find engaging. To build an initial group of followers, we involved a group of young people contacted by the associations and searched among university students from different fields; they were expected to act as peer-to-peer ambassadors and co-creators of the content and “evangelizers” [33].

A specialized communication agency, chosen by our partner CNCA, should be tasked with creating the profile, including posts, stories, images, and short videos. Themes and issues would be provided monthly by an editorial team composed of representatives of the peer-to-peer ambassadors and our partners. Every three months, we needed to analyze the profile’s analytics using specialized tools, such as those provided by the platform and the application Just Analytics.

The design of this profile, initially developed in collaboration with our partners, was to be focused on discussing sexuality and sexual health using language and tone suited to the platform and the preferences of young audiences. This approach was intended to be implemented with a clear, informational perspective, drawing guidance from feedback provided by ambassadors and prospective followers over time. The profile’s project included interactive content, such as quizzes, interactive health service maps, scheduled events, and storytelling of first-hand experiences. We also designed sections featuring literary, musical, and film events related to the topics. A landing page linked to the Instagram profile also served as an institutional site, providing detailed project descriptions and additional information for interested individuals. This landing page also would have facilitated measuring conversion rates in the analytics, serving as a further indicator of content interest provided by the platform and the application Just Analytics.

Our profile design, initially developed in collaboration with our partners, focused on discussing sexuality and sexual health using language and tone suited to the platform and the preferences of young audiences. This approach aimed to be implemented with a clear, informational perspective, drawing guidance from feedback from ambassadors and prospective followers over time. The profile project included interactive content, such as quizzes, interactive health service maps, scheduled events, and storytelling of first-hand experiences. We also designed sections featuring literary, musical, and film events related to the topics. A landing page linked to the Instagram profile also served as an institutional site, providing detailed project descriptions and additional information for interested individuals. This landing page would also facilitate measuring conversion rates in the analytics, serving as an added indicator of content interest.

However, towards the end of this first semester, some organizations revised their approach and invited the strategist from the communication agency involved in a previous project3 to present an alternative design for the Instagram profile. This design deemed the objective of providing information as secondary since it assumed that the Instagram audience primarily seeks entertainment, social interaction, and novelty. The aim shifted towards creating a profile that would attract users intrigued by sexual content, catering mainly to their desire for fun and only partially engagingly covering the issues of prevention. The tone of the content was intended to be light, incorporating black humor, healthy cynicism, irony, and provocation as its main characteristics, developed mainly by the agency without substantial external collaboration. There would be no indication of the source or the content creators for the profile nor a landing page explaining the project, based on the assumption that young people distrust institutions and are indifferent to the source of the information. The specialized agency, composed of professional communicators, was responsible for deciding and producing the content, focusing on various sexual experiences, including enjoyment, anxieties, fears, tips, tricks, and discussions on gender and LGBTQI+ rights. Secondary prevention topics, such as HIV, AIDS, sexually transmitted diseases, transmission, therapies, and HIV testing, would also be addressed.

In the two distinct designs of the Instagram profile, contrasting methodologies of health communication via social media emerge. The first perspective emphasizes participatory empowerment through a blend of information and entertainment, using language that resonates with youthful tastes without presenting sexual topics merely as a form of entertainment. A balanced mix of infotainment, co-created with a group of engaged young people, could foster active engagement and peer-to-peer information dissemination. Therefore, this first perspective does not aim to attract supposedly apathetic individuals seeking only entertainment. Instead, it assumes that, in the medium–long term, sustainable attitudes and behaviors arise from the constant growth of awareness and knowledge. Listening to young people’s needs and preferences is vital, as well as learning their languages and using their communication channels. However, this does not mean treating them as apathetic and passive, deserving only superficial entertainment. Young people are not a homogeneous group defined solely by age; several factors influence their interests and behaviors. Viewing less educated or less interested individuals as mere targets for entertaining content undermines their potential for empowerment and growth. Conversely, a participatory and peer-to-peer communication strategy on social media does not underestimate the symbolic power of knowledge. Although limited by unequal opportunities, peer-to-peer diffusion remains a potent tool for effective empowerment in health communication to allow the growth of a social understanding.

The second perspective, on the other hand, embraces a marketing model of communication [35] that prioritizes attracting attention first and subtly incorporating superficial information. It adopts a communication strategy that aims at capturing the social media audience with themes and images relating to sexuality to marginally push a few prevention topics, aligning with the advertising model of propaganda persuasion. This approach is more familiar and accessible, reflecting the widespread use of propaganda tools in political, commercial, and social communication. The clear advantage lies in the immediate response, particularly regarding the number of followers, significantly when leveraging the advertising tools available on social platforms. Moreover, in a country like Italy, where publicly discussing sexuality is still challenging, this method effectively de-escalates the topic by providing alternative information, such as on the use of female condoms or tips about different sexual positions provided in a humorous tone.

The organizations eventually opted for this second design since it aligned more closely with their idea of a “young” perspective and appeared more straightforward to understand and manage over time. Given the collaborative methodology of the StIngS project, our research team accepted the associations’ decision and chose to limit our contribution to monitoring activity, data analysis, and verification. At the same time, the design and creation of the profile became a task under the responsibility of CNCA on behalf of the seven organizations involved in the project.

The communication agency, funded by the CNCA partner’s project resources, launched the @sextagram_official profile on Instagram on 19 September 2022. The communication strategist met once a month with representatives from the partner organizations to present the content plan, typically focusing discussions on inclusive language, i.e., using an asterisk to avoid gender-specific endings in Italian nouns and adjectives. There was no substantial debate on gendered and potentially problematic imagery used in some posts, nor regarding the content created by the agency related to sex or prevention.

Methods of Monitoring

We monitored the Instagram profile for 14.5 months until the project’s conclusion on 5 December 2023. We accessed analytics provided by Meta, the platform’s owner, supplemented with data from Just Analytics and qualitative analysis of the few comments on posts and direct messages received by the profile from followers. Our study included: (a) the number of followers and their declared socio-demographic characteristics (age and gender); (b) reach (the number of unique accounts reached by the content); (c) impressions (the number of times content was viewed) or reproductions for video content like reels; (d) engagement rate, calculated on the number of actual users reached, considering it more indicative of engagement effectiveness, especially given the paid promotions characteristics; (e) comments by followers.

Additionally, every six months, we aimed to conduct at least 15 in-depth interviews with the ambassadors who were supposed to follow the profile and provide their comments or suggestions. Unfortunately, most of the members of the initial group of 43 young people who had committed to collaborate gradually stopped following Sextagram. Consequently, we had to recruit other individuals aged between 18 and 25 (the target group initially identified by the project) who had become followers of the profile and were willing to share their comments every six months. We managed to find nine new participants for the interviews in each of the two semesters, in addition to the six from the initial group who chose to continue their collaboration until the end.

The group of 18–25-year-olds available for two rounds of interviews during the profile’s publication consisted of eleven girls and four boys, with a female over-representation. Their declared sexual orientations included ten heterosexuals (six females and four males), three bisexual girls, one homosexual girl, and one self-declared queer individual (registered as female). Most participants were from northern regions (12 out of 15). Ten were students (nine at university–equally distributed from STEM4, humanities, and social sciences degrees—and one in a technical—professional high school), and five were working professionals with university degrees. Based on the parents’ professions, the class indicator showed a predominant lower middle-class background.

In April and November 2023, we conducted unstructured face-to-face interviews with each of the 15 participants, lasting between 20 and 35 min, depending on their availability. The primary objective was to gather comments and feedback on the profile’s content and formats and to solicit suggestions for future activities.

While qualitative investigations inherently have limitations due to the small sample size, which serves primarily to identify significant insights, we are aware of the additional restriction posed by the composition of the interviewee group. This fluctuation could reflect the negative reception of the profile among those interested in prevention topics and potentially broaden the comparative basis.

Towards the end of the project, in November and December 2023, we interviewed eight representatives of the partner organizations alongside five experts in sexual health communication to collect their overall perception and evaluation of the profile’s performance. The aim was to identify critical issues and strengths and reflect on how to strengthen future communication actions on prevention aimed at young people.

3. Results of the @Sextagram_Official Profile

3.1. Data from Analytics and Posts’ Key Content

As of 5 December 2023, Sextagram had amassed 4040 followers and followed 283 profiles. The follower count increased consistently over the profile’s activity period, likely influenced by paid promotions managed by the agency.

Many followers (46.1%) declared that they belonged to the 18–24 age group or the immediately adjacent age group 25–34 (33%), thus aligning with the target audience envisaged by the project. However, from May 2023, we noted a decline in the 18–24 age group to 39.3%, with a consequent increase distributed across the higher age groups. As regards the gender variable, however, the percentages remained unchanged throughout the period considered (44% male and 56% female).

Over the months, Meta for Instagram provides data only for the first five cities followers declare as their location. Therefore, we know that about 18% of them come from seven large Italian towns. While the capital, Rome, in Central Italy, is the most common city of residence among the Sextagram followers (8%), followers are also found in Milan (2.9%), Turin (2.2%), Genoa (1.4%), and Bologna (1.5%) in Northern Italy, as well as Naples (1.1%) and Palermo (1.4%) in Southern Italy.

Between September 2022 and September 2023, the agency utilized paid promotions for all content on the profile to achieve two primary objectives: (a) acquiring new followers to enhance profile visibility and (b) enhancing the engagement rate (or the reach content in the case of carousel posts, which cannot be boosted for engagement purposes). However, paid promotions were discontinued after September 2023, resulting in a noticeable decline in reach and engagement. Overall, the campaigns effectively increased profile visibility, with 37% of the reached audience acquired through paid promotions.

As of 5 December 2023, after 14.5 months of activity, the profile had published 142 posts on Instagram, including 52 static images, 62 carousels, and 28 reels. Additionally, 313 stories were published, with 150 of these posted between 5 May and 5 December. These stories were typically related to the theme of the day’s post, aiming to promote it further or initiate a dialogue with followers through Instagram tools such as message boxes and survey responses. Unfortunately, this dialogue rarely yielded productive outcomes, as will be discussed further.

Regarding the thematic dimension, 31 out of 142 posts (approximately 22% of the total) addressed topics related to prevention and information. These posts covered various aspects, such as the use of male and female condoms and, to a lesser extent, sexually transmitted infections (STIs), specifically HIV/AIDS. This percentage has remained relatively stable throughout the entire period of Sextagram’s activity, indicating that the communication strategy has consistently dedicated a minority of content to prevention issues since the launch. Prevention content appears as “push” type information5, with the profile more frequently focusing on topics related to sexuality and gender identities. This approach is also evident in the choice of themes for the periodic columns that have characterized Sextagram’s content:

• #theytoldmedthat, false myths and “urban legends” about sex.
• Super Quhard is an informative look at sex in an ironic way (joking about the title of the famous television broadcast SuperQuarck aimed at scientific dissemination).
• Ero Talks is a series of reels learning about one’s body and sexuality.
• Sexting, ironic posts about sexuality and digital communication.
• Hot Stuff, on sex and the most common practices.
• OraScopo (a joke on the Italian words for Horoscope and Fuck now) is an ironic approach to the zodiac signs to talk about sexuality.
• Tips, advice, and suggestions to improve your sexual experience.
• Identity is a series of information carousels on different gender identities and sexual orientations.
• 3 big words, three words relating to sex and prevention explained in an informative way.
• Let’s talk about a series of information carousels on STIs.
• The ImpiccAno game (again, a joke on the Italian words hangman-hang-anus), a version of the classic sexual-themed hangman game to involve followers.

The analytics data suggest that users respond more positively to posts related to sex, sexual practices, and gender identity than those focused on prevention and STIs. The most viewed post, published on 6 July 2023, significantly exceeded the profile’s average view count. This post, created for National Kissing Day and celebrated in England, featured a carousel of images offering tips for better kissing.

Reels published on the profile, such as the column on false myths about sex (#theytoldmethat) and other content on sexuality and sexual practices, also showed higher engagement. Notably, the video on oral sex and sexually transmitted infections was the most viewed prevention-themed reel.

In summary, when comparing all posts according to the coverage variable—which indicates the number of unique accounts reached and is calculated by Instagram for all content categories—

Table 1. The ten most “viral” posts on Sextagram (by number of accounts reached).

Title	Post Type	Description
#theytoldmethat beer foam makes breasts grow	Reel	Column on false myths about sex
How to make out	Carousel	Tips on how to kiss better on Kissing Day
#theytoldmethat the first time always hurts	Reel	Column on false myths about sex
The name of your vagina is…	Reel	Ironic reel about the names that can be given to one’s vagina
Sex for Pisces	Carousel	Column dedicated to the sexuality-themed horoscope
Bullshit sex advice	Reel	Ironic reel listing some bad sex advice
Oral sex and STIs: let’s clarify	Reel	Reel which explains the relationship between oral sex and STIs
In bed with Capricorn	Carousel	Column dedicated to the sexuality-themed horoscope
Sex for Aquarius?	Carousel	Column dedicated to the sexuality-themed horoscope
The taste of happiness	Carousel	Insight into the connection between sperm and nutrition

lists the ten most successful Sextagram posts. The only post addressing a prevention topic in this list is the “reel” on oral sex and STIs, while the #theytoldmethat and OraScopo columns performed well.

Measuring the engagement rate of users who view the content is helpful in terms of engagement. This rate has been calculated for the total coverage of each post rather than the total number of followers, providing a more accurate measure of engagement6. Over the 14.5 months of activity, the average engagement rate was approximately 3%, but overall, user interaction levels show a highly irregular trend, largely dependent on individual content and influenced by paid promotions.

Table 2. The top 10 posts for engagement and saves (17 September 2022—5 December 2023).

Post	Engagement Rate	Saves
What is consent	12.6%	550
Pride month	12.5%	176
Sex during period	11.9%	164
What is a Spanish (with the feminine ending in Italian, evoking a sexual meaning, but also a Spanish girl or the old Spanish flu)	10.1%	163
Does female masturbation exist?	9.1%	160
Asexuality	8.8%	156
#they told me that if you have sex standing up, you cannot get pregnant*	8.8%	125
New Jersey Car Sex Law	8.5%	122
Here are the 4 big words of the week	8.4%	117
World Aids Day 2023	7.6%	105

presents the top ten posts published by Sextagram in terms of engagement rate and number of saves. Instagram allows users to save posts in a private profile section, a significant indicator of particular interest in the content. The analytics data observe the highest engagement rates in posts related to contraception or sexual practices that ironically reinterpret certain stereotypes. None of the top ten posts in Table 2 addresses issues related to prevention or information on STIs. The only content linked to these themes is a post celebrating World AIDS Day 2023. Interestingly, this post recorded the lowest coverage ever for the profile, reaching only 500 unique accounts. Thus, we understand the complexity of verifying the effectiveness of posts, considering both coverage and interaction capacity7.

3.2. Data About Interactions

We now turn to the qualitative results concerning user interactions with the profile. We examine issues raised by comments left on posts, responses received through survey boxes in stories, and messages sent directly to the profile inbox.

During its activity, the profile received 265 visible comments on 142 posts as of 5 December 2023, indicating a limited propensity for followers to engage personally. The two most commented posts addressed asexuality as an orientation (13 December 2022) and female masturbation (16 January 2023), with 19 and 18 comments, respectively. Other posts that sparked discussion included those on the distribution of contraceptive pills in Italy (7 March 2023), free condoms in France (3 February 2023), and the use of the vaginal ring (15 May 2023). Additionally, two posts that used “pregnant*” to avoid gender-specific endings in Italian (24 January 2023 and 15 August 2023) also garnered attention.

Usually, the comments were not very meaningful; most discussions started from a contentious point, addressing topics such as the definition of gender identities and sexual orientations, the inefficiencies of the national health system concerning sexuality and contraception, and the taboo nature of subjects like female masturbation. However, aside from these discussions, most comments were brief, expressing approval or irony in line with the profile’s tone, often using emojis. Occasionally, more critical observations about the superficiality of the content emerged. Notably, posts on prevention and STIs received fewer interactions and comments, rarely sparking user discussions.

Other direct interactions occurred through direct messages (DMs) to the Sextagram inbox and responses to open survey boxes in stories. The number of users requesting information or asking questions about profile topics remained stable at 26 since the launch in September 2022. This communication channel was used for private questions about sexuality, seeking further details than what was presented in posts or stories. These private exchanges confirmed that followers were primarily interested in sexual practices, such as tips for oral sex, increasing penis size, or female masturbation without vibrators. In response, the partner organizations provided two experts to the agency for short, informed answers. Only two instances involved further information on European Testing Week, and two short messages were appreciations from experts; given the profile’s entertainment tone, we observed a minor presence of practical-informative research on prevention.

Regarding responses to survey boxes in stories, there were 103 in total. These messages were typically brief and ironic, responding to questions posed by Sextagram. Most of these stories are related to sexuality and sexual practices. However, some boxes on condoms and HIV launched between September and December 2022 received a few responses related to STIs or pregnancy prevention topics, such as questions about contracting HIV from oral sex or information about female condoms.

3.3. Comments from In-Depth Interviews with Youngsters

As written down in the previous methodological section, interviews were conducted every six months with 15 individuals aged 18 to 25 who were available to follow the profile throughout the year. None of the interviewees reported engaged interaction; one participant initially attempted to make a suggestion but did not receive an immediate response from the agency responsible for the profile’s content.

Interviewees usually appreciated the idea of using informal and fun language to discuss sexual topics, as these are often considered taboo in educational and interpersonal contexts, limiting opportunities for shared understanding. Except for one interviewee who noted a lack of graphic consistency, which hindered the establishment of a recognizable identity, most liked the attention-grabbing colors and images. The majority valued the recreational content, which sometimes alternated with informative content, although they noted that the information was never addressed in a “technical” or in-depth manner. Overall, many interviewees found the ironic and distracting tone positive, attracting their attention and encouraging them to read or browse, sometimes learning something new or wanting to delve deeper. However, they did not find such insights within the profile, nor were direct links provided for further information. Few specific content memories emerged; those that did pertain to lesser-known information, such as making insights about the female condom more accessible. Others mentioned OraScopo posts or “big words about sex” as humorous. Two interviewees specifically recalled a post related to the series on STIs.

Several critical observations also emerged, divided into three main categories:

• One-third of the interviewees reported that the language and formats sometimes bordered on cringeworthy, seeming more suitable for middle school children than for 18- to 25-year-olds, as if the profile’s speaker were a parent attempting to explain something amusing about sex to a child in a condescending manner.
• An interesting issue emerged regarding the “myths of sex” column: the risk of ambivalence. The content was read superficially without clearly indicating it was a myth. Hence, in the rapid scrolling of Instagram, the phrase intended for debunking might remain in memory. Some interviewees, including the only 18-year-old, felt the selection of myths was bland and outdated, suggesting more concrete ones.
• A minority of interviewees (4 out of 15) raised concerns about the lack of continuity between informative and entertaining content. They worried that attention might be captured temporarily but not instructively. One interviewee noted a lack of coherence, while another pointed out the randomness of topics, with comical jokes jumping from one subject to another. However, some found this approach enjoyable, albeit potentially banal or even risky, if it ended up presenting a stereotypical image of sex to younger audiences.

Regardless of their stance, both critics and supporters of the profile appreciated the idea of combining prevention information with irreverent and entertaining discussions on sex and sexuality. Interestingly, another commercial Instagram profile with over 800,000 followers, run by a company selling sexual toys, was often cited as either similar in content or richer in tool analysis. It presented itself in its bio as a source for “discovering, discovering yourself, and fucking. 1st shop for everyone’s pleasure”.

Finally, interviewees provided several suggestions, indicating areas for further exploration regarding the social dimension of sexuality today and an implicit call for better positioning or recognizability of the profile. Most of the suggestions were informative and experiential, highlighting typical aspects of online-mediated interaction practices [37]:

• Short videos featuring people sharing their experiences with STIs or gender identity.
• Videos on sex and sexual health by healthcare workers, experts, or organization representatives.
• Practical information related to the topics addressed (e.g., where to take tests and exams, how to book, and links to reference websites).

In summary, despite the over-representation of girls and young people, mostly university-educated residing in northern regions, among our interviewees, we can draw some interesting insights.

• The @sextagram_official profile aligns with the Instagram format and, although not always followed assiduously, is appreciated for its graphics and for addressing sex-related topics, rarely covered in institutional or school settings.
• The playful intent and a few informative aspects are recognized and appreciated, capturing attention and arousing curiosity.
• There is a lack of in-depth preventive information, with most information appearing rare or primarily ephemeral. Someone made a connection with a commercial profile created to sell erotic products for pleasure, aligning with progressive needs to overcome prejudices that taboo sex or tie it to a binary gender identity.
• Attention is drawn to the risk of ambivalence, particularly in the “myths about sex” section, which may need revision. Additionally, some interviewees noted the possible cringeworthy nature of certain jokes, deemed unsuitable for audiences aged 18–25.
• Finally, there is an interesting overlap between contraception and STI prevention topics, with the former being mentioned most frequently.

3.4. Comments from In-Depth Interviews with Partner Organizations

Overall, the organizations expressed satisfaction with the quantitative results achieved by Sextagram, judging it to be a positive experience. However, some critical and self-critical observations emerged regarding the issues addressed during the 14.5 months of activity. We can categorize their observations into three thematic groups:

• Main strengths of the project:

  1.1.

  Sextagram provided a valuable experiment in communication languages and strategies, allowing a departure from classic institutional communication codes and closer alignment with the practices and habits of young audiences on social platforms. The introduction of an ironic/light tone and the de-tabooing approach to sexuality was effective in avoiding stigmatizing messages regarding young people’s behaviors and identities.

  1.2.

  The chosen strategy successfully achieved quantitatively satisfactory results regarding followers, coverage, and content views.

• Critical issues:

  2.1.

  Organizational difficulties arose within the research consortium, partly due to differing sensitivities among partners. Identifying a strategy for creating and managing the profile required several months of discussion and mediation to reach a consensus supported by the majority.

  2.2.

  Content creation and agenda structuring (theme and topic selection) were entirely delegated to the communication agency and strategist. The organizations could have taken on greater responsibility in this process, potentially dedicating more space to prevention topics.

  2.3.

  Some organizations needed more inclusive language in posts during monthly editorial plan meetings. The differing sensitivities struggled to reach a consensus on a consistent practice for the content. Some organizations felt too much emphasis was placed on this theme, noting that Sextagram’s primary audience likely lacked the necessary sensitivity to grasp all nuances. Attention to gender was mainly limited to linguistic refinements, with little discussion on the use of images associated with a stereotypically male and potentially degrading gaze.

  2.4.

  Sometimes, the ironic tone was overused when a more direct and detailed approach could have been beneficial.

  2.5.

  The overall level of follower engagement remained too low.

• Suggestions and ideas for future projects:

  3.1.

  Actively involve groups of young people in creating, discussing, and disseminating content with small remuneration.

  3.2.

  Increase the role of partner organizations in creating content and defining the profile’s agenda.

  3.3.

  Create a landing page with detailed information about the project, its promoters, and valuable resources for those seeking services, counseling, support, etc.

  3.4.

  Include content beyond static graphics, such as direct testimonies on project topics, and generate more in-depth material.

3.5. Comments from In-Depth Interviews with Experts

Experts interviewed raised similar points while also adding interesting insights:

• Highlighted strengths of Sextagram’s page:

  1.1.

  Effective use of language and expressive codes suitable for a young audience.

  1.2.

  A communication approach that rethinks traditional campaigns, using a de-tabooing tone that aligns with the ironic language often used by young people while cautioning against cringe-type effects.

  1.3.

  Content that can be useful during outreach actions, recommending a “simple” source of information attractive to young people unfamiliar with prevention issues.

  1.4.

  Positive results in terms of follower quantity and frequency of published content.

  1.5.

  Pleasant, captivating, and fun graphic design, in line with what young people are accustomed to on Instagram.

• Critical issues:

  2.1.

  Risk-based prevention messages (e.g., posts on STIs) could arouse fear rather than encourage behavior change.

  2.2.

  Greater depth in content is needed, especially when providing practical guidance or information on STIs, medical devices, or sexuality (e.g., posts on the menstrual cup or the clitoris).

  2.3.

  Some content used particularly assertive phrases (e.g., “Always use your imagination,” referring to sexual practices).

  2.4.

  The proportion of posts on prevention and STIs is too low compared to other content.

  2.5.

  More informative graphics and topic succession coherence could strengthen the followers’ connection about interests, expectations, satisfaction, and engagement with the profile. Again, respondents observed the lack of videos and testimonials, which are particularly popular with younger audiences on social media.

  2.6.

  There is an implicit representation of sexual “pleasure” that appears to have a specific male imprint, especially in the “carnal” dimension, which does not fully encompass the broader sexual experience.

4. Discussion

Identifying clear indicators of the efficacy of the Sextagram Instagram profile for prevention purposes is challenging. Moreover, in general, “more studies are needed exploring the relative impact of different applications of social media in health interventions on health outcomes” [38]. As some authors remember, several research gaps exist in this area: “Further robust and comprehensive evaluation and review, using a range of methodologies, are required to establish whether social media improves health communication practice both in the short and long term” [39]. Furthermore, along with the constraints linked specifically to challenges associated with conducting social media research in general [40], the rapid evolution of social media platforms and the diverse ways users engage with health content add to the complexity of measuring the impact of Instagram profiles on health information and outcomes.

In our case study, the change in design approach also influenced the evaluation and measurement of the project’s effectiveness. Specifically, losing the participatory role of peer-to-peer ambassadors, who were supposed to have an integrated and active role in managing the profile, necessitated the adoption of alternative steps for qualitative checks, in addition to the technical approach focused on achieving quantitative objectives (number of followers, KPIs) set by the communication agency. Although no significant attention was given to community formation that could stimulate debate and co-construct content, we showed some detailed indications of empowerment among the youth targeted by the StIngS project. Our young respondents remained willing to provide feedback and suggestions throughout the project despite the challenges the agency’s content creators faced in implementing them.

Verifying the content’s effectiveness through platform analytics and qualitative analysis of reactions revealed that the profile exceeded the quantitative goals set by the project. The number of followers after one year was four times the minimum expected threshold (estimated at 1000 followers), indicating strong interest and follower favor for the type of content, aided by a well-implemented paid advertisement plan by the agency. The continuous paid promotions made evaluating organic results more complex. While the overall engagement rate appeared optimistic, it relied heavily on likes and savings—metrics linked to targeted promotion via paid promotions—offering limited opportunities for analyzing interactive comments. The data from the last two months showed a decline in numerical performance once paid advertisement was discontinued in September 2023. Throughout the profile’s 14.5 months of activity, active user engagement (in comments, messages, and content collaboration) remained sporadic, limiting the potential for meaningful qualitative analysis and audience feedback.

During the project’s final phase, participants realized the absence of a landing page—a website with a limited number of pages and elements as outlined in the first editorial plan—hindered the ability to measure a “conversion rate.” Such a page would have provided additional reliable resources for in-depth analysis of topics addressed on the Instagram profile and enhanced transparency by detailing the project’s promoters. The lack of data on conversions from profile visits to website visits deprived the project of a significant indicator of interest, which Instagram’s features alone could not satisfy.

The editorial management of the profile was primarily handled by the agency, with the editorial plan presented and discussed monthly in meetings with partner organizations’ representatives. However, these meetings were too limited to impact the agenda and thematic choices for prevention significantly.

End-of-project interviews with organization representatives, followers, and ambassadors highlighted a critical issue: the lack of in-depth analysis of the themes addressed by the content. The focus on capturing attention through brief informational posts limited the potential for a more progressive study that could have developed over time.

Despite these challenges, Sextagram’s analytics trends offered valuable insights into engaging younger audiences using digital tools like social media. Time and budget constraints limited long-term verification possibilities, making it unclear whether a reference community could arise around Sextagram. The potential for participation and collaboration with young ambassadors, influencers, and other social platform participants remained unexplored. The agency faced difficulties in creating video testimonials requested by interviewees and forming alliances with micro-influencers or developing a landing page to collect data on potential conversions between “push” type communication (attracting followers with sexuality-focused content) and “pull” type information (offering opportunities for in-depth analysis and empowerment).

Regarding the profile’s content, our results show how it is necessary to rethink and expand the chosen formats. Going beyond the visual approach could be beneficial by alternating static images (currently all graphic-based) with short videos or reels featuring real people. The objectives are multiple:

• “Humanize” the profile by featuring young people to build trust, credibility, and loyal relationships. These subjects can also stimulate identification, facilitating the process of community building around the profile and its content.
• Experiment with different storytelling strategies that can effectively transmit complex information without reducing everything to a graphic image, which is not always immediately apparent.
• Offer an effective format for sharing stories and experiences (testimonies), which could be very strategic for addressing specific issues still considered taboo.
• Provide an additional opportunity to be favored by algorithms, potentially guaranteeing a higher reach for the posts without paid promotions.

Additionally, it is crucial to re-launch the participatory role through a strategy involving young ambassadors, ensuring active participation from the planning phase of the editorial plan (through focus groups and meetings led by a facilitator and topic expert) to the content creation phase. As some recent studies show, it is prominent to “co-design a social media communication framework for health messaging to young people” [41]; see also [42]. Engaging young people as content creators, with continuous support from experts and active collaboration from partner organizations, can help prevent the loss of participants experienced in the first phase of our project. This approach can capitalize on their ability to disseminate and promote content across personal networks, including sharing profile content on different platforms. The central objective remains to drive substantial traffic to the profile, attracting users intrigued by their peers (peer-to-peer communication) who initially come to satisfy a specific interest or curiosity but eventually find a wealth of empowering information [42].

Finally, we must reflect both on the difference between the two methodologies of health communication we faced at the beginning of the project and on the representation of sexuality in health communication aimed at preventing STIs. How and on what basis do we propose content and specific visions of sexual practices? Some young interviewees noted a similarity between the ironic, de-tabooing, but predominantly “carnal” content of Sextagram and the commercial profile of a sex shop, which promotes sexuality as mere pleasure for sales and profit purposes. While a marketing model of communication [35] might view this comparison as a compliment, given the popularity of the commercial profile, social communicators should consider the ethical and civic implications of promoting a one-dimensional view of sex and sexual practices, even when the goal is STI prevention.

5. Conclusions

Our case study highlights how, in enforcing an effective health communication strategy, Instagram should not be designed to be the only communication channel, maintaining its role as the primary touchpoint for the main target audience. Key recommendations include employing a multi-channel strategy [3,43], creating a supportive and informative landing page, and fostering participatory content creation with young ambassadors. For instance, based on the data from this first year of experimentation, the need to build a landing page associated with the project was reinforced. Additionally, periodically investing in offline tools (such as posters in schools, cinemas, city buses, and locations near schools or sports centers) could help reach a broader audience capable of spreading word-of-mouth to younger individuals, thereby increasing profile visibility and engagement.

Despite its limits, future social health communication projects aimed at prevention and knowledge can draw valuable insights from this experience for effectively utilizing social media platforms to engage young audiences and the questions they pose. Can the entertainment approach raise questions about the value of making young people laugh about sex? Who does this attract, and for what purpose? While de-stigmatizing taboo topics can be beneficial, it is crucial to consider the medium-long-term goals and the nature of the audience attracted—an ephemeral fan base about which little we know. In the digital environment of social media, passive engagement, often characterized by distracted likes, can be mistaken for meaningful participation. As Lazarsfeld and Merton already observed in 1948 about the mass media [44], media consumption data rarely significantly impact behaviors or attitudes, often leading to superficial interest and hidden apathy: exposure to continuous communication can produce a “narcotizing dysfunction”, while modern societies need active, “well-informed citizens” [45]. Therefore, the core question concerns the role of health communication socially oriented, mainly when applied in social media: do we need a persuasive marketing communication strategy to maximize the social control of people’s behaviors, or can we focus on awareness and empowerment of citizens?