Evaluating Use of Mass-media Communication Intervention 'MTV-Shuga' on Increased Awareness and Demand for HIV and Sexual Health Services by Adolescent Girls and Young Women in South Africa: An Observational Study

"...highlight the importance of evaluating the real-world scale up of promising interventions to understand both the reach and population effect as well as inform interventions to increase impact and equity."



Mass media campaigns have the potential to reach a large number of people and have been shown to improve knowledge and health behaviour of a range of health conditions, including HIV/AIDS. However, the key ingredient to the success of multicomponent interventions is the extent to which adolescent girls and young women (AGYW) and their male partners, who are most at risk for contracting HIV, will take up and adhere to the active components of the intervention. This observational study sought to investigate the effect of exposure to MTV Shuga: Down South (MTV Shuga-DS) during the scale-up of combination HIV-prevention interventions on awareness and uptake of sexual reproductive health (SRH) and HIV prevention services by AGYW in South Africa (SA).



MTV Shuga is a mass-media behaviour change campaign that uses entertainment-education to improve sexual and reproductive health rights (SRHR). At the centre of the campaign, which includes radio and social media, is a TV drama that weaves messages about HIV, family planning, transactional and intergenerational sex, sexual identity, and safer and healthy sexual relationships into storylines with young characters. The fifth series of MTV Shuga (MTV Shuga-DS), a weekly serial edu-drama designed for SA, was broadcast on free-to-air on SA national television starting March 8 2017 for 12 weeks (with repeats). The show's characters explicitly model how to discuss issues that are sensitive or taboo. MTV Shuga uses the technique of "melodramas", where drama is created through the battles between stereotypical good and bad people, and where the "transitional" (often empathetic) character begins as ambivalent but changes into a positive role model to promote positive behaviour change. AGYW, or at least early adopters, are anticipated to be immersed in the serial, able to classify and identify with the transitional characters and their outcomes. Pathways to behaviour change through MTV Shuga, therefore, relate to the extent to which the observer, including early adopters, are immersed and critically engaged with the story. (For more, see Related Summaries, below.)



The study sought to determine the extent to which MTV Shuga-DS would increase demand for, and uptake of, existing combination individual and community-based SRH and HIV prevention services for AGYW in 4 diverse SA settings, including uMkhanyakude, a socioeconomically deprived rural district with an extremely high burden of HIV: 40% antenatal HIV prevalence and an annual HIV incidence of 5% in girls (15-19 years) and 8% in young women (20-24 years) and in 3 high-prevalence urban districts (HIV prevalence of greater than 10%) of City of Johannesburg, Ekurhuleni, and eThekwini. One longitudinal cohort (rural uMkhanyakude) and 3 cross-sectional surveys (urban areas) of representative samples of 6,311 AGYW aged 12-24 were conducted between May 2017 and September 2019. Using logistic regression, the researchers measured the relationship between exposure to MTV Shuga-DS and awareness of pre-exposure prophylaxis (PrEP), condom use at last sex, uptake of HIV-testing or contraception, and incident pregnancy or herpes simplex virus 2 (HSV-2) infection.



Self-report of watching at least one MTV Shuga-DS episode was 14.1% (cohort) and 35.8% (cross-section), while storyline recall was 5.5% (cohort) and 6.7% (cross-section). In the cohort, after adjustment (for HIV prevention intervention exposure, age, education, and socioeconomic status), MTV Shuga-DS exposure was associated with increased PrEP awareness (adjusted OR (aOR) 2.06, 95% confidence interval (CI) 1.57-2.70), contraception uptake (aOR 2.08, 95% CI 1.45-2.98), and consistent condom use (aOR 1.84, 95% CI 1.24-2.93), but not with HIV testing (aOR 1.02, 95% CI 0.77-1.21) or acquiring HSV-2 (aOR 0.92, 95% CI 0.61-1.38). In the cross-sections, MTVShuga-DS was associated with greater PrEP awareness (aOR 1.7, 95% CI 1.20-2.43), but no other outcome.



The finding of a differential association of MTV Shuga exposure with awareness of PrEP, compared with uptake of HIV and contraception, suggests that while educational mass entertainment may be able to increase awareness and possibly demand for a service, it does not impact on accessibility of the service. Well-described barriers to uptake of HIV testing and contraception in this area are: internalised and externalised stigma, fear of judgment from healthcare workers, and the social costs of accessing care in busy primary healthcare settings. Behaviour change intervention, including mass communication campaigns, can be constrained or facilitated by the context in which people live. To optimise MTV Shuga's effect, there may need to be parallel innovations in SRHR and HIV service delivery that makes the services easier to access.



Also, as noted above, the behaviour change theory that underpins edu-drama as a vehicle for mass behaviour change communication explicitly suggests that the audience, and especially the early adopters, need to be actively watching, rather than passively watching or listening. TV watching in rural homesteads can be in the context of large, often grandparent-led households and competing chores and priorities. This fact, coupled with the relatively late air time of the shows, may explain why so few girls and young women were sufficiently engaged or immersed to be able to recall characters or story lines. Moreover, the timing of this analysis may have allowed insufficient time for early adopters to convey the message of the show to others in their networks.



In conclusion, among both urban and rural AGYW in South Africa, MTV Shuga-DS exposure was associated with increased PrEP awareness and improved demand for some HIV prevention and SRH technologies but not sexual health outcomes. However, exposure to MTV Shuga-DS was low: One of the limiting factors for the effective use of TV-based edu-drama may be the dose that young people are exposed to, particularly in rural and resource-constrained settings most affected by HIV. Given these findings, supportive programming may be required to raise exposure and allow future evaluation of edu-drama impact in this setting.