Developments in the Use of the Mass Media at the National Level for HIV/AIDS Prevention in South Africa: Evaluation, Impact and Cost effectiveness

loveLife and Soul City have well-developed evaluation strategies. Both reflect developments in this field and their evaluation aims to measure the overall impact of their respective programmes. The loveLife strategy is developed using expertise from Cambridge University in the UK. This strategy is population-based and aims to provide behavioural and biological indicators that are monitored over time. In their evaluation of Soul City 4, Soul City observe that the evaluation period of 8 to 9 months between baseline and evaluation measurement is relatively short. This, they argue, could well impact on the likelihood of detecting measurable behaviour change giventhe complexity of this process, highlighting one of the difficulties faced in this type of research.

Beyond Awareness II was criticised at the end of their campaign period for failing to have any assessment of their impact.[25] Although they had evaluated many of their component parts, they had no evidence of the impact of their mass media campaign or of the campaign as a whole. The call rates to the AIDS Helpline were reported to increase with advertising bursts, but there was not any attempt made to factor in other programmes that also promoted the call line such as Soul City or any other provincial initiative. At one site in their sentinel site research, 81% of respondents had heard of the Helpline. However, Beyond Awareness is not alone, since GCIS do not have any impact data of their media advertising.

In their evaluation of the 4th series, Soul City has tested their theoretical model and demonstrated a "dose" related response. (The greater the "dose" or amount of Soul City to which the respondent has been exposed to the more likely he/she is to adopt health-seeking behaviours.) Black African respondents who saw Soul City TV were significantly more likely to say they always use condoms. Thirty-two percent of African respondents with high Soul City TV exposure said they always use condoms, compared to 31% with medium and 28% with low Soul City exposure. Young respondents (16-24) exposed to Soul City were also more likely to say they always use condoms. Thirty-eight percent of those who watch Soul City television a lot always used condoms.In comparison, 26% of those who watch television, but did not watch Soul City, reported that they always used condoms. The evaluation goes on to show how Soul City is associated with significant increases in inter-personal communication, positive perceptions of subjective socialnorms, decreased negative peer pressure, intention to change behaviour and maintaining positive behaviour.[26] This they have summarised in the diagram below, demonstrating a hypothesised outline of the mechanism of behaviour change for South Africans.

Figure 5: Hypothesised outline of mechanism of change – interpersonal discussion, subjectivenorms, decreased negative social pressure and behaviour change in relation to exposureto Soul City

A recent literature review of the economic impact of HIV/AIDS on South Africa and its implications for governance, highlights the fact that to date there is no national behavioural surveillance programme in South Africa[27]. Cadre, the authors of this report, quote the 1998 Demographic and Health Survey, the Beyond Awareness sentinel site youth study in six sites across South Africa, and one survey of reproductive health issues among urban black youth, as studies that give some cross-contextual data with any indication of behavioural response to HIV/AIDS. The authors argue that other evaluations, such as that done by Soul City, are reductionist because ultimately they are only there to report on the impact of Soul City. loveLife state that their five year plan for research and evaluation aims to establish a national surveillance system showing trends incommunication, behavioural change and biological markers. However, this does not address the present need, nor provide a system to incorporate other research sources.

Without a national centre that tracks behaviour change, debates rage between practitioners in the field about the current picture of HIV/AIDS-related behaviour. A recent internet exchange about loveLife is an example of this. To underpin their own strategy and use of the mass medialoveLife quote the following statistics.

" …South Africa spent some 11 years and millions of Rands on the traditional HIV messaging... to littleeffect. The result is 98% awareness of HIV and virtually zero behaviour change. Condom usage across all population groups has remained almost unchanged at 12% for more than five years.[28]

However, not everyone would agree with this picture. Instead it is argued by Parker that there is "wide ranging evidence in numerous studies of youth behaviour in South Africa that condom use is high, and that it has increased appreciably over the past five years."[29]

To support his argument, Parker estimates that 280 million condoms were distributed or soldduring 2000 and that this equates to 224 million acts of safer sex. He then quotes figures from theantenatal HIV and STD prevalence study that show there is a decline in prevalence over threeyears – in particular amongst youth. HIV prevalence in the under 20 age group has declinedfrom 21% in 1998 to 16.9% in 1999 and 16.1 % in 2000. Parker believes that there is plenty ofevidence in South Africa that youth are able to understand prevention messages and choose asafe option. loveLife themselves show that only 54% of 16-17 year olds report being sexuallyexperienced. Of those youth who are not sexually experienced, 77% of young men and 75% ofyoung women report that they would use a condom or insist on their partner using a condom.A smaller percentage, 55%, of young people who are sexually active report that they always usea condom when they have sex.[30]

In addition to the disputing of facts between programmes, there is a danger that importantconsiderations are overlooked. For example, the loveLife survey of youth shows that youth wholive in rural areas are more likely to be sexually experienced than those who live in a metropolitanarea (34% v. 26%). Beyond Awareness found in their sentinel site research that poor and ruralcommunities are lower on most prevention indices.[31]Soul City 4 is reported to have reached 16.2 million youth and adult South Africans.[32] This represents 79% of its target audience. However, the reach into rural populations of the TV series and the print media is not as great as into urban communities.

Table 1: The reach of the Soul City 4 media into urban and rural populations

Soul City media	% of urban target group reached	% of rural target group reached
TV series	75	60
Radio series	52	68
Print media	69	58

loveLife states that 71% of rural South Africans know about them[33] although they cannot say what the impact of this is. They refer to a number of media strategies to serve rural communities such as 120 branded water tanks in communities without reticulated water, two outdoor broadcasting units in rural KwaZulu-Natal and Eastern Cape and the Love Train used as an outreach vehicleto rural towns. Despite this, the question that is left unanswered is who takes responsibility to ensure that mass media interventions are reaching rural and poor communities and that these communities do not remain behind with respect to prevention indices.

One other statistic used by loveLife as a measure of their impact are the 60 000 calls made per month to the loveLife sexual health helpline. This figure is double the present call volume to the national AIDS Helpline. However, the value of helplines should not be overstated. One of thefindings at the sentinel sites used by Beyond Awareness Research is that most young people when asked where they would get further advice about AIDS said health sources are favoured above other sources. Doctors, health educators, community AIDS groups and nurses were the topfour answers. The telephone was the tenth option. In general, the critical role of health workers in HIV/AIDS prevention is overlooked. This is a missed opportunity because, as the UNAIDS strategy discussed at the beginning of this chapter recognises, interpersonal communication iscritical for HIV/AIDS prevention.

Some of the results of the evaluation of Soul City 4 are interesting in this regard. The impact of careful "pro-social" role modeling is shown in their evaluation to go far beyond individuals. In their evaluation of the 4th series, there is a powerful case study of an informal settlement area in Mamelodi, Gauteng that renamed itself "Soul City". The case study gives qualitative insights into the process unfolding in this community. However, what is striking is how closely the community identifies with the people of the Soul City TV series and their struggle for development.

"Well, for us the people, we are thinking that we will be like those in the Soul City programme – thatthings will change, and that we will one day get a better place than this one. We are really desperate for achange. That is why we can not give up our goal of having a better place, so we are looking for a betterdevelopment."[34]Soul City's latest evaluation suggests that "pro-social" modeling found in their edutainment format is a powerful mechanism to effect change in individuals and communities. The specific community factors that appear to be impacted on by this approach include more caring service delivery, better understanding of issues and a change in attitudes and awareness by community leadership and an impact on community action and events. All of this is captured in another model detailed in the evaluation report, but not included here.

Internationally, there are very few costing studies of mass media interventions. Soul City estimatethat the cost per person reached with each HIV/AIDS message is very low, 44 cents for televisionand 5 cents for radio. There are no such figures from loveLife or Beyond Awareness II. The detail in the Soul City evaluation has assisted them to develop measures of cost effectiveness. The primary measure is the cost of an increase in knowledge, behavioural intention or action. They show that an increase in HIV/AIDS knowledge is 41 cents, behavioural intention is 46 cents and action is R2,70. [35]

In their discussion they note that most cost-effectiveness studies of HIV prevention programmes use the potential number of HIV transmissions averted as the primary outcome measure. In their present study the behavioural data is insufficient to allow modeling to this final outcome, but the progress made by Soul City in the field of evaluation is commendable.

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25 Coulson, N., Goldstein A strategic appraisal of Beyond Awareness II and HIV/AIDS communication 2001-2003,Department of Health, September 2000.

26 Soul City. Soul City 4 - Evaluation Integrated Summary Report, July 2001, p.49.

27 Cadre. The Economic Impact of HIV/AIDS on South Africa and its Implication for Governance, USAID, November 2000.

28 Nokwedi, J. What's going on with loveLife? 19 September 2001, available by clicking here

29 Parker, W. What's going on with loveLife? September 2001, available by clicking here

30 loveLife. Hot Prospects Cold Facts: Portrait of Young South Africa, Henry J Kaiser Foundation, 2000.

31 Kelly, K.J. Communicating for Action: A contextual evaluation of youth responses to HIV/AIDS, Beyond Awareness Campaign, Department of Health, 2000, p.5.

32 Soul City. Soul City 4 - Evaluation Integrated Summary Report, July 2001, p.10.

33 Harrison, D. loveLife campaign unprecendented in size and scope, loveLife, 2001.

34 Soul City. Soul City 4 - Evaluation Integrated Summary Report, July 2001, p.69.

35 Soul City. Soul City 4 - Evaluation Integrated Summary Report, July 2001, p.84.