A STREETWISE RESPONSE TO HIV. The Story of Scrutinize

Transcription

1 A STREETWISE RESPONSE TO HIV The Story of Scrutinize

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3 Acknowledgments A narrative of this kind relies hugely on the unpublished documents, the memories and the insights of many individuals who were involved in various facets of Scrutinize. Thanks are due to the following people who shared their knowledge and contributed to various aspects of this document: Richard Delate and Darryl Crossman of Johns Hopkins Health and Education in South Africa; Cal Bruns and Jason Coetzee of Matchboxology; Ana Oxlee-Moore of Mediology; Mkhonzeni Gumede of Drama AIDS Education; and Helen Hajiyiannis of the Centre for AIDS Development, Research and Evaluation. Researched and Written by: Jo-Anne Collinge, Dr Maria Elena Figueroa, Dr Larry Kincaid, Richard Delate, Bronwyn Pearce JHHESA 2013 This Street Wise Response to HIV: The Story of Scrutinize was made possible through nancial support provided by the President s Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development. Disclaimer: The views expressed in this report are those of the authors and contributors and do not necessaril reect the views of D

4 Index Acronyms and abbreviations 1 1 Introduction 2 2 The evidence behind scrutinize 3 3 Target audiences and objectives 4 4 Models for social and behaviour change 4 5 Serendipity and Scrutinize: the creative phase 6 6 Scrutinize moves into action Forging the partnerships 7 6. Final pre-testing and rst ighting Content and messaging 9 Scrutinize creatively 10 Consider its characters Negotiating for maximum exposure Digital platforms Interpersonal communication 16 Scrutinize creatively 17 7 Evaluation of Scrutinize Extended parallel process model in action Findings from a Qualitative reception analysis Quantitative Impact evaluation The Cost Benet Analysis 37 8 Concluding remarks 38 References 40

5 Acronyms and abbreviations AIDS CADRE CCMS DramAidE FET HIV HSRC JHHESA JHU JHU CCP MCP NCS SABC SBCC UNICEF Acuired Immunodeciency Syndrome Centre for AIDS Development, Research and Evaluation Centre for Communication, Media and Society, University of KwaZulu-Natal Drama AIDS Education Further Education and Training institution Human Immunodeciency Virus Human Sciences Research Council Johns Hopkins Health and Education in South Africa Johns Hopkins University Johns Hopkins University Center for Communication Programs Multiple and concurrent partners or partnerships National (HIV) Communication Survey South African Broadcasting Corporation Social and behaviour change communication United Nations Children s Fund 1

6 1 Introduction The Scrutinize campaign centred on a range of fastpaced, information-packed, straight-talking animated adverts straight off the city streets. The appearance of the rst of these animerts on television screens in July 2008 marked a fundamental shift in the culture of HIV communication in South Africa. What made Scrutinize unique was not so much what it said, but how it said things. The themes and messages featured in the Scrutinize campaign were a mixture of established messages delaying sexual debut, consistent condom use, and the risks of intergenerational and transactional sex and newer messages that were enjoying currency at the time. The latter focused on multiple and concurrent partners (MCP), sexual networks and alcohol as an HIV risk. ictor dons a orld up hat for the 2010s crutinie ed ard campain Scrutinize, the rst initiative undertaken under the banner of the USAIDJHU HIV Communication Programme 1, went much further than previous HIV campaigns in meeting ordinary young South Africans on their own cultural turf. The language it used was a colloquial version of English, liberally peppered with indigenous language phrases and unique township expressions. It was the language of the streets a language that resonated with the intended audience. The tone of Scrutinize was light-hearted, irreverent, blunt and above all, egalitarian. The characters who provided advice were not paragons of virtue but part of robust urban life. It depicted high risk sexual behaviours and the consequences of these in an uncompromising way. The campaign had a special aesthetic appeal. Not only did it employ animation, with its proven youth appeal, but the characters were endearing, the settings bright and lively, and the pace of delivery quite hectic. The television animerts were backed by a dedicated website, a Facebook prole for the main animated character, taxi driver Victor Scrutinize, and an interpersonal component initially focusing on the campuses of higher education institutions and extending later to further education and training (FET) institutions, selected schools and community settings. Extensive training of peer educators took place, producing thousands of young people capable of facilitating the range of discussions outlined in a facilitators guide. 1 The proramme was underpinned b a veear partnership between the nited tates enc for nternational Development D and ohns opins niversit enter for ommunication rorams in the nited tates with implementation b outh frican ohns opins ealth and ducation in outh frica 2

7 2 The evidence behind Scrutinize A detailed examination of the pattern of HIV infection in South Africa and the behaviours that drive or curtail the epidemic was undertaken in the introduction to this series of stories on elements of the USAIDJHU HIV Communication Programme. This analysis included factors that informed the development of Scrutinize and a summary of relevant information is reproduced here for easy reference. At the time Scrutinize was planned, the results of the national uman ciences esearch ouncil urve of 2005 (Shisana O, Rehle T, Simbayi LC et al, 2005, referred to hereafter as HSRC 2005) and the ational ommunication urve of 2006 (Kincaid DL, Parker W, Schierhout G et al, 2008, hereafter referred to as NCS 2006) were available to guide strategic decisions. In addition, two qualitative studies undertaken by the Centre for AIDS Development, Research and Evaluation (CADRE) were signicant in shaping the Scrutinize campaign. The major national surveys indicated that: One in 10 South Africans in the year age group was living with HIV and that prevalence was particularly high among women in this age group (HSRC 2005). Two out of three South Africans did not believe they were at risk of infection although a good many of this group of non-believers were already infected. (HSRC 2005). Only 7% of the adult population was aware that the risk of HIV infection could be reduced by reducing one s number of sexual partners. (NCS 2006) Condom use among women of all ages and men over the age of 25 years was low. (HSRC 2005) Condom use was also much lower with regular sexual partners than in casual sexual encounters or short-term relationships (NCS 2006). More than a quarter of men in the year age group reported having had two or more sexual partners in the last 12 months. (HSRC 2005) The qualitative research included the following studies by CADRE: Talin about D in an informal settlement: a community study in rane arm auten which highlighted transactional sex, the oster based on study by D and others on multiple sexual partners 3

8 role of shebeens in paid sexual encounters, and the fact that inter-generational sex involved vulnerable young men (with older female partners) as well as young women with older men. It also revealed the link between structural drivers of HIV notably poverty and unemployment and high risk sexual behaviour. The study underscored the reality that sexual activity in the context of poverty is commodied and sex provides the currency through which to meet diverse needs. (Parker W and Hajiyiannis H, 2008) A second CADRE study called oncurrent exual artnerships amonst youn adults in outh frica: hallenes for prevention communication, collected information from ve provinces. It found the practice of multiple partnerships to be widespread, explored the diverse (and inaccurate) denitions of faithfulness, and the role of alcohol in casual sex. The notion of faithfulness in many cases was not equated with monogamy but with having a main partner and protecting that partner from knowledge of other more casual relationships. The study concluded that there was a need to raise awareness of the risks of high partner turnover, casual sex and concurrent sexual relationships. (Parker W, Makhubele MB, Ntlabati P and Connolly C, 2007) 3 Target audiences and objectives Scrutinize dened its primary audience as young people of both sexes between the ages of 18 and 32 years, the age range in which most HIV infections occur. The overall objectives of the Scrutinize campaign were to: Increase the number of young people delaying their rst experience of sexual intercourse. Increase perception of the risk of HIV infection arising from multiple and concurrent sex partners. Reduce the number of people with multiple and concurrent partners. Promote correct and consistent condom use with all partners. Increase the number of people who test for HIV on a regular basis. (Johns Hopkins Health and Education in SA, Undated) 4 Models for social and behaviour change All JHHESA communication programmes are founded on the social ecology model of transformative communication. This highlights the existence of factors that inhibit or promote individual attitude and behaviour change in a hierarchy of nested social systems, beginning with the family and social networks, and expanding from there to the local community and ultimately, the wider society. Some of the practices that Scrutinize set out to inuence, such as transactional sex and multiple sexual partnerships, were embedded in social traditions and economic 4

9 survival strategies. To have an impact on these aspects of HIV risk-reduction it would almost certainly be necessary to mount a campaign that went beyond the mass media, interacting with people in community settings and securing the participation and endorsement of respected individuals and organisations in these communities. Scrutinize had an interactive component focused on university campuses, schools and communities in which partners were working. The qualitative studies that informed Scrutinize suggested that certain material or structural factors beyond the inuence of communication, such as unemployment and poverty, might militate against change in respect of some behaviours (such as transactional sex) but not necessarily in respect of others. In addition to the social ecology model of social and behavioural change communication (SBCC), JHHESA applied the evidence that strategies combining fear-based messaging with self-efcacy messaging can produce motivation for behaviour change. The approach requires that those who are exposed to fear-inducing messages: Are given a clear solution to the adverse situation depicted. Have condence that the proposed solution actually works. Have the know-how, the condence (self-efcacy) and the practical tools to carry out the required action. This combination of inducing fear and building efcacy is commonly referred to as the extended parallel process model of change (Witte K and Allen M, 2000). In South African health promotion practice it has been used in relation to road safety and anti-tobacco campaigns, but prior to Scrutinize there were strong reservations about employing the extended parallel process model in relation to HIV prevention. The concerns were that it might not be possible to build efcacy sufciently to spur members of the public into constructive action. On the contrary, it was reasoned, fear-based messages might freeze people into inaction. JHHESA initiated Scrutinize in a context where meaningful gains had already been made in South Africa in the areas of condom use and uptake of HIV testing. Furthermore, some of the dread and stigma surrounding HIV and AIDS had been reduced by the implementation of a free antiretroviral treatment programme in the public health sector. HIV infection no longer led inexorably to premature death. As a result, it now seemed possible to achieve a productive balance between fearinducing and efcacy-building elements in HIV communication programmes and Scrutinize became, in effect, a test case. crutinie was extremely frank almost confrontational about various HIV risks and clear about risk reduction actions. There were often quite detailed explanations for these actions. The animerts also depicted social situations in which various HIV risks arise, enabling viewers to anticipate them. 5

10 5 Serendipity and Scrutinize: the creative phase Scrutinize, as South Africa has come to know it, was a product of a chance meeting at the right time between Cal Bruns, director of the creative agency Matchboxology, and JHHESA s then communications head, Richard Delate. It came at a point when Matchboxology was incubating a radically new approach to HIV communication and JHHESA was grappling with ways to tackle specic drivers of the epidemic highlighted by the research referred to earlier in this document. Matchboxology originated the Levi s brand Red for Life campaign and in the process became aware of a hunger for more relevant information on HIV among young people who simply weren t getting what they wanted in order to make important life choices. Levi s gave Matchboxology funding to do experimental creative work in the area of HIV communication. We said, let s do what no-one else is doing. We were thinking of humour and a campaign with a clear hook that people could relate to and giving them the information they wanted, recalls Bruns. He draws a clear distinction between the people-centred approach of Matchboxology and the problem-centred approach of social scientists, of giving people a product they want rather than one they are considered to need. We must be clear there was no brief for Scrutinize, no formal process, says Bruns. It was just a matter of people with expertise coming together in a process we call design incubation... Scrutinize would never have happened in a traditional situation. No funder would have funded it. The paradigm was just so different it needed a prototype to convince partners. The incubation team included a creator of animated lm and well-known comedian Joey Rasdien who gave the experimental venture its hook, the word scrutinize used specically in the context of sexual relationships. Rasdien, who also provided the unforgettable voice of the main animated character, taxi driver Victor Scrutinize, reasoned that viewers who spoke English as a second language and really didn t know what scrutinize meant at the start of the campaign would begin to understand it from the context. Scrutinize is an important word. It s my word. I invented it, Rasdien relates on the Scrutinize website. It means you watch out for yourself. Watch your own back. Watch your own front, too. In fact, watch all your risks. ( oey asdien leads a crutinie ampus event 6

11 Although JHHESA did not commission Scrutinize, Matchboxology had not lost sight of the organisation as a potential partner and took the two prototype animerts to show them. After initial research on audience responses to the animerts and consideration how these mass media products might anchor a broader campaign, JHHESA proposed that Scrutinize become a major project within the USAIDJHU HIV Communication Programme funded by USAID. 6 Scrutinize moves into action The granting of USAID funding signalled the end to Scrutinize s incubation period and its emergence as a national mass media and interactive campaign. Many of the standard checks that characterize evidence-based campaigns, such as pretesting of concepts and adverts and partner consultation on creative work, began to kick in. However, the integrity of the original creative concept remained intact because JHHESA shared Matchboxology s view that doing things better meant having the courage to do things differently. The other major change was the expansion of the team working on Scrutinize, from a tiny group of hand-picked creatives to a network of individuals with diverse skills and experience. 6.1 Forging the partnerships The core of the Scrutinize action team set up by JHHESA comprised the following organisations: USAID/PEPFAR, the primary funder in terms of its ve-year agreement with Johns Hopkins University Bloomberg School of Public Health. The Johns Hopkins University, Bloomberg School of Public Health, Center for Communication Programs in Baltimore, which served as a strategic and research partner for all JHHESA interventions implemented under the above agreement. Matchboxology, the agency which incubated Scrutinize and created the animerts. It became the cornerstone of the campaign partnership put together by JHHESA. Matchboxology continued to create animerts, designed a range of campaign collateral and became involved in the face-to-face aspect of the campaign by contributing to the production of a training manual and the management of large events. LS&Co., as part of the Levi Strauss & Co. Red 4 Life Campaign, Levi s provided support for the development of the original animerts and the Scrutinize campaign identity which was then paired with the new Scrutinize champions, the USAIDJHU HIV Communication Programme to expand the campaign. Levi s also sponsored the use of Levi s T-shirts for peer educators and as campaign give aways during 7

12 interactive live events. CADRE, the research organisation in South Africa which had provided much of the evidence that shaped JHHESA s denition of Scrutinize objectives. CADRE continued to support the campaign through pre-testing of specic campaign products and concepts and dip-stick research on the early public response. Mediology, a communications consultancy that specically undertook the media planning for the campaign. Mediology dened its primary task as increasing the total value of airtime available for Scrutinize and negotiated with various media companies for extraordinary amounts of added value. This large donation of additional airtime effectively turned the relationships with SABC and e.tv from pure commercial transactions into partnerships. Drama AIDS Education (DramAidE), acknowledged for its experience in the eld of interpersonal communication, especially among young people. DramAidE trained large numbers of peer educators to facilitate interactive sessions based on the Scrutinize animerts and the themes they addressed. It also organised outreach activities at universities, schools and in communities, in partnership with local structures. 6.2 Final pretesting and rst ighting The detailed pre-testing of Scrutinize involved submitting both the concept and the animerts to focus group scrutiny. By the time of the launch, CADRE researchers were condent that the animerts would resonate with young people and be comprehended. The rst three Scrutinize animerts launched on television in June Several rounds of dipstick testing were done at intervals after they hit the screens. You certainly saw how this brand was developing together with [viewers ] understanding of the messages and how one advert was building on the others, recalls CADRE s Helen Hajiyiannis. We knew the creative concept was reasonably on track. People liked (the main character) Victor, they liked his voice. Only the rst two animerts were made experimentally; the process of developing the rest was somewhat more conventional, with the health-related priorities derived from evidence in the usual JHHESA fashion. Concepts were also pre-tested by CADRE and adjustments made in the light of audience feedback. Additionally, Matchboxology continued to ensure that more voices of ordinary people informed the way issues were framed and solutions were presented. We would go out with a video camera and talk to people on the streets, look for insights that can t come from the experts. For example, we spent time in shebeens listening to the language that people used, learning about the way people have sex in the toilets. That s how we came up with the scoreboard [in the Booza brain animert]. (The scoreboard registered every time someone scored in the shebeen toilets.) (Cal Bruns, Matchboxology) Planning and preparation for the interpersonal element of Scrutinize began before the 8

13 rst animerts were broadcast and Scrutinize was live on university campuses before the end of The period between October 2009 and September 2010 represented the peak of Scrutinize. The number of spots featuring the animerts exceeded over this period and a special community outreach initiative for both Scrutinize and Brothers for Life (another JHHESA campaign) was organised to coincide with the period around the 2010 FIFA World Cup in South Africa. Messaging in two of the animerts was re-themed for the World Cup. 6.3 Content and messaging Scrutinize will probably be best remembered for its tagline, Flip HIV to HI Victory, with the irrepressible Victor giving the V sign. However, it was underpinned by a complex and consistent set of messages that kept the spotlight rmly on multiple and concurrent partners and the related matters of transactional sex, inter-generational sex, alcohol and sexual risk-taking, the acute infectious period and consistent condom use with all partners. The content of various animerts is summarised in the gure below. Scrutinize was unusual in its inclusion of quite detailed scientic and technical information in its adverts (for example on the acute period of infectivity and why condoms are reliable). 9

14 Figure 1: Scrutinize animerts and their content Undercover HIV Explains the window period and advocates condom use What s my risk Checks out various behaviours and rates their HIV risk Undercover lover Explains why HIV infection risk goes up with multiple partners Condom wise Examines common beliefs about condoms and advises on proper use Booza brain Shows how alcohol clouds the brain and increases HIV risk Love words Warns that words of partners and reality are not always the same Drive slow Urges young people to wait until they re ready to have sex Sugar surprise Looks at risk of HIV infection in transactional intergenerational sex Ninjas in ya Explains the period of maximum infectiousness and sexual network Red card World Cup version of animert on alcohol related HIV risk Dangerous passes World Cup version of multiple and concurrent partners animert 10

15 The secret to Scrutinize s immediate connection with many people, particularly in the target age group, was probably related to its selection of characters and its use of language. These were the key to Scrutinize avoiding the expert or elitist tone that occasionally inltrates mass media education. Some examples are presented in the box below. In Scrutinize the HI virus was represented visually as a stealthy, dangerous little black ninja-like creature. The proposal to do this came from Matchboxology because, as Cal Bruns explained, it was clear to us that people had no image of HIV in their minds. Coming from an advertising background where the strategy of personication had been used with huge success, he was convinced that it could help the HIV prevention cause provided the right person could be found to represent HIV. The ninja appeared to be the right t. This idea ew in the face of HIV education conventions and some were reportedly were reportedly sceptical that it would work. But Independent testing of the little ninja gures showed that the public associated them with precisely the characteristics that the campaign wished to emphasise about HIV. Listen to the language of Scrutinize Undercover lover [script] So there s lekka things out there, nê. Check out this malume over here. Ja, so he s got a big house and threez small houses. But this one s got a minister of transport, housing and culture. He s got his cougar... her sugardaddies... his shebabs and side dishes, makhwaphenis and a spare wheel. Check, HIV comes to visit just one of them and we got 169 problems in no time. Exponential growth! Eliminate the element of surprise. Stop the spread. An undercover lover will bring you HIV from another. Eliminate the element of surprise. Scrutini-i-ize! Flip HIV to HI Victory. Undercover HIV [script] Ek sê hey you! You want to beat HIV? Know your enemy. Scrutini-i-ize! Check this bra out. The rst few weeks HIV invades the body like a ninja. Chameleon philosophy. Its natural defences can t see the attack. So you test negative, negative, negative. It s at this point unfortunately that the virus is at its most infectious that it will ever be. You can t see it because it s undercover. That s why this bra looks and feels so ne. So eliminate the element of surprise, my friends. Be safe use condoms all the time. HIV-test yourself regularly. Eliminate the element of surprise. Scrutini-i-ize! Flip HIV to HI victory. 11

16 Consider its characters VICTOR SCRUTINIZE Played by comedian Joey Rasdien Victor is a taxi driver.taxi drivers are not exactly the best-loved people. They are seen as pushy (read aggressive), rude and impatient but a necessary evil because they offer a vital service. Victor is an unlikely advisor on how to run your sex life. But maybe that s what makes us believe him. Victor addresses concerns about government issued hoice ondoms SHEBEEN QUEEN VICTORIA Played by actor Welile Tembe Shebeen queens hold a special place in township folklore. On the wrong side of the law in apartheid days, shebeen queens doled out hospitality with a very rm hand, maintaining a feminine identity in a male-dominated environment. They ve seen it all but, like bar keepers worldwide, they are a listening ear and a source of wise counsel. Ideal for Scrutinize! The hebeen ueen gives sassy but good advice 12

17 elile Tembe oey asdien and atchboxology celebrate the hua ward crutinie acilitors uide Vaal niversity of Technology students ed ard bad behaviour ow to se a ale ondom crutinie full page posters in the unday Times in partnership with 13

18 crutinie murals in priority districts and ive events on campuses 14

19 6.4 Negotiating for maximum exposure JHHESA recognised that effective media planning requires specialised knowledge and selected Mediology through a competitive process to undertake this function. Not only was Mediology able to carry out the complex channel and programme selection to reach Scrutinize s target audience optimally, but it used its established relationships with media houses to leverage USAIDs advertising spend. From October 2008 to 2012, USAIDPEPFAR contributed 42% towards the advertising airtime for Scrutinize, while the South African media companies contributed an additional 58% of airtime (by value), elevating them from service providers to signicant partners in the Scrutinize campaign. (Mediology,2012). This enormous donation of advertising time undoubtedly had a critical inuence on the numbers of people who said they had seen Scrutinize and were able to explain its content or complete its pay-off lines. (See evaluation below). It also justied the large production budget entailed in creating a wide range of adverts. Scrutinize utilised public broadcast channels SABC1 and SABC2, commercial free-to-air channel e.tv, subscription entertainment channel Mtv and community channel Soweto TV. This combination ensured that the campaign reached young people across the socio-economic spectrum. Figure 2: Number of Scrutinize TV spots (TAMS) As Table 1 indicates, a high proportion of the target audience and total viewing audience was reached with the purchase of about 400 spots. Increasing the number of spots yields benets in terms of the average number of times each viewer was exposed to Scrutinize. In the 2009 nancial year (The nancial year here is from 1st October to 31 September), the average frequency of viewing Scrutinize was 72 times per viewer. This obviously allowed for the ighting of several different animerts and for message reinforcement. Table 1: Audience reach and frequency of exposure to Scrutinize Year # of spots Target Audience Reach Reach % Complete audience Frequency Reach Reach % June 2008-Sep % % 21.3 Oct 2008-Sep % % 57.7 Oct 2009-Sep % % 29 Oct 2010 Sep % % 23.6 Oct 2011-Sep % % 12.6 Target audience includes youth aged omplete audience includes all persons aged 4 years and older Frequency 15

20 Outdoor advertising in the form of wall murals were designed and displayed at venues frequented by young people, such as mobile phone repair shops and cafes. 6.5 Digital platforms Scrutinize has a dedicated website which recorded visits over the course of four years. There was for a period a Facebook prole in the name of Victor Scrutinize and JHHESA staff responded to his odd friends. For some viewers Victor was so real that they would conde in him on line, sharing condences that they said they had been unable to tell anybody else. 6.6 Interpersonal communication The objectives of the Scrutinize interpersonal component included: Strengthening the gains made through mass media communication and encouraging behaviour change. Producing a cadre of trained peer facilitators capable of conducting ongoing Scrutinize training. Utilising the infrastructure and relationships of community partners both for capacity building and for community-based Scrutinize activities. large proportion of the outreach activities focused on engaging young people in educational institutions such as secondary schools universities and tertiary institutions The interpersonal campaign was mounted by a combination of JHHESA partners: The KwaZulu-Natal NGO DramAidE played a key role in providing master trainers to equip thousands of peer educators to take the Scrutinize campaign forward, and in organising campaign activities on 23 higher education campuses as well as in various communities. Matchboxology and JHHESA produced a compact training manual with discussion points and activities related directly to the rst seven animerts. Matchboxology was also primarily responsible for the Scrutinize Live events that combined the use of music, entertainment and the provision of counselling and testing which marked the end of several days of Scrutinize activity in communities and on campuses. DramAidE played a signicant role in organising these events. The USAIDJHU HIV Communication Programmes community partners in KwaZulu- Natal, Free State and Gauteng took Scrutinize on board and ensured that their peer educators and other outreach staff were trained and able to use the Scrutinize materials and messaging in their ongoing educational work in communities. The dedicated manual The Scrutinize manual was compact and its content was entirely focused on expanding 16

21 the content of seven animerts through discussion and activity. While Matchboxology and JHHESA wrote and produced the manual, DramAidE s experience of using drama and activities in the exploration of issues is evident in the content. Typically, each module of the manual consisted of: A section headed The experts Scrutinize which briey reviewed the evidence behind the animert s main messages. A central section on facilitating the discussion, including questions to ask participants. A section entitled Scrutinize creatively which outlines activities games, drama, song and writing related to the messages. (Johns Hopkins Health and Education in SA, undated A) Scrutinize creatively Here are some of the activities contained in the Scrutinize facilitation manual. The sexual network Place a ip chart at the front of the room. Select one participant and ask himher to... draw a circle with hisher name in it and then select two other participants as his her partners. Ask each of them to draw a line from the circle of the rst participant and at the opposite end a circle with hisher name in it. Each of these two people then select two further partners who each draw a line from the name of the partner to a circle containing their name. Tell participants they can select partners who are already someone else s partner, if they like. Keep going until all participants have added their names to the chart. Randomly choose one participant and give this person a red marker to show that heshe was recently infected with HIV. Then use the red marker to show how HIV will spread through the network, to the HIV- positive individual s, their partners, and their partners partners (and so on). Booza brain Ask the participants to construct a dramapoempostersong about the key messages of the animert and to perform it. Have the group debate and provide comment: is it an accurate portrayal of what is happening in their communities? Do they have suggestions on what can be done to address the situation? Write up suggestions on a ip chart. The Risk Game All participants are given a green and a red card. They are asked to evaluate the risk in various situations and show either a green card (for low risk) or red card (for high risk). For each situation, one participant is asked to explain hisher choice of either the red or green card. Alternatively, two participants who have chosen different colours can be asked to debate the question. ource: crutinie: a guide to facilitating crutinie creatively 17

22 Capacity building and campaigning The training of peer educators and on-the-ground Scrutinize activities were largely integrated into a single process. When Scrutinize came to town or to campus, peer educators would be trained, they would immediately begin to organise outreach activities and the process would usually culminate in a major Scrutinize Live concert, held in partnership with the Levi s Red for Life initiative. Ultimately, more than peer educators were trained to deliver the Scrutinize campaign in face-to-face situations. DramAidE director Mkhonzeni Gumede rates the campus interventions as most successful because there was an existing HIV prevention infrastructure. Scrutinize was taken to 23 campuses of higher education institutions where DramAidE had full-time health promoters in place in an effort to strengthen the higher education sector s response to the epidemic. These health promoters were in a position to recruit peer educators and had valuable links with the campus health services, AIDS programmes and the university administration. Frequently, the higher education institutions were able to contribute resources to the Scrutinize intervention on campus. Since all universities have a community service mandate, their AIDS programmes sometimes extend into neighbouring communities. In these instances, student peer educators carried Scrutinize dialogues and activities into surrounding residential areas. Campuses therefore had both the resources and structures to sustain Scrutinize outreach activities for several months after the excitement of the Scrutinize Live event had receded. The interventions with the USAIDJHU HIV Communication Programmes community partners such as The Valley Trust, Lesedi Lechabile and Mothusimpilo also yielded good returns, according to Gumede. Once again, Scrutinize could take advantage of existing teams of outreach workers, strong relationships with other community structures, and management systems. Furthermore, these partners received funding from USAID to undertake prevention work, so the incidental costs were covered. There was the prospect of a reasonably sustained intervention in these communities, Gumede reckons. Likewise, DramAidE, had some established projects focusing on out-of-school youth in the Emdeni area of KwaZulu-Natal, the Sterkspruit area of the Eastern Cape and some locations in the Western Cape. Scrutinize was an expansion of work already in progress in these communities. However, there were also community initiatives where ad hoc partnerships were forged purely to undertake face-to-face Scrutinize campaigning. The organisations involved, such as NGOs and local authorities, often had different work styles and cultures and also lacked the resources to sustain an educational effort, in Gumede s view. 18

23 7 Evaluation of Scrutinize This section considers the degree to which Scrutinize embodied its chosen theoretical model, the extent to which its target audience accessed the campaign, and the evidence provided by qualitative and quantitative studies that Scrutinize had an impact on knowledge, attitudes and behaviours that it set out to inuence (in terms of its formal objectives). 7.1 Extended parallel process model in action Scrutinize was identiable as an instance of the extended parallel process model in action. The animerts clearly rested on twin representations: the behaviours that increase the risk of HIV infection (shown in a fear-inducing manner) and the actions that can be taken to prevent infection (efcacy to respond). There was a specic initiative to build public condence in the primary HIV prevention technology the male condom. The portrayal of risk behaviours was strong and, in most cases, unequivocal. The use of popular terms to refer to high risk sexual practices made the identication of these behaviours more powerful and credible. Several animerts explained why the identied behaviours represented a special infection risk. The desired risk-reduction behaviours were clearly advocated: periodic HIV testing, correct and consistent condom use, partner reduction, avoidance of alcohol-fuelled sex and approaching transactional trans-generational sex with an appreciation of the inherent risk. 7.2 Findings from a Qualitative reception analysis Markdata, an independent market research company, undertook a reception analysis of Scrutinize in October 2009, conducting a total of 15 focus groups in urban and peri-urban areas of six provinces. Of these groups, 12 comprised young adults in the age groups and years, and the remaining three consisted of parents of adolescents. (Markdata, 2010) The groups discussed the seven original animerts, all of which had been seen and recalled by at least 50% of the participants. Eight out 10 participants recalled seeing What s my risk and Booza brain, while Undercover HIV, Undercover lover and Condom wise were seen by more than 70% of participants. Meanings associated with scrutinize Few participants were able to give a dictionary-type meaning for the word scrutinize. Nearly all interpreted it within the context that the campaign had placed it. Scrutinize was associated with: 19

24 Examining or inspecting one s lifestyle and sexual behaviour. Taking precautions to prevent HIV infection. Being aware of and informed about HIV. There were some misinterpretations but these were quite few in number. Some participants indicated that scrutinize had crept into everyday language as a warning to use a condom. The characters and the actors Victor, the main animated character, was the second most liked character in the campaign. He was seen to be a teacher who helped people watch out for themselves. However, some participants failed to register that Victor was the main character and connecting thread across the animerts. And others stereotyped him as a promiscuous taxi driver. The following comment is illustrative: We are not bound to take all the advices Victor gives... He s a taxi driver. Today he sees this girl, tomorrow he sees another girl. So you can t be sure if he scrutinizes. (Female, years, Mpumalanga) Other ndings related to characters and actors were: The shebeen queen in Booza brain was the best liked character. She was perceived to take care of her customers in a motherly way. The character Rich Daddy, who preys on young women, was liked by 22% of men, apparently for his obvious afuence and success. The voices of celebrities Joey Rasdien and Welile Tembe, who recorded the voices for the two best-liked characters, were not recognised. Celebrity Sophie Ndaba, who was depicted as herself, was recognised and positively received. Perceptions of the ninja-like virus Markdata described animerts that featured the ninja as the HI virus as highly successful. Most participants felt the ninja indicated that HIV spreads fast in the absence of protection and some referred to its silent transmission. The main slogan The main slogan, Together we can ip HIV to HI Victory, was found to be partially established. Some participants thought the competing slogan, Eliminate the element of surprise. Scrutinize! was the primary slogan. The word ip was sometimes misconstrued or replaced by another word and the notion of doing things together was often lost. Most participants considered the idea of uniting to defeat HIV believable. 20

25 Power to initiate discussion Participants presented mixed responses to the question on whether Scrutinize had prompted them to discuss HIV prevention. Some (more females than males) said yes, others said no. Some said they would discuss the funny bits but ignore the underlying message. Parents varied in their experiences; most felt it made discussion with their children easier, but a few did not agree. Impact on knowledge, attitudes and behaviour Markdata prefaced its comments on the apparent impact of Scrutinize with two clear caveats: The conclusions were drawn on the basis of self-reported responses and it was possible that participants faked good for the sake of providing socially desirable answers. (Markdata, 2010) All participants had been exposed to a range of HIV campaigns and programmes and within the scope of the focus group methodology it was not possible to draw a direct causal link between Scrutinize and impacts mentioned. Markdata also observed that participants in 14 of the 15 groups reported some change at the level of knowledge, attitudes or behaviour but, when asked whether they saw changes in others, several participants said they detected no visible change. With these general comments in mind, Markdata recorded that participants reported the following changes as a result of Scrutinize: Common self-reported changes in knowledge: The importance of using condoms. The effect of partner reduction. The risk of alcohol use in relation to HIV. The role of sugar daddies and transactional sex. How easy it is to get infected with HIV. Common self-reported changes in attitudes: An increased sense of caution and less trust of others. A tendency to pause and think, or scrutinize. A more serious attitude to HIV. Greater motivation (among women) to insist on using condoms. Common self-reported behaviour changes: Keeping to one partner. Using condoms. Being more cautious about sex when drinking alcohol. Being more open to discussing HIV. Interesting responses to particular animerts The summary below extracts some of the main ndings on six of the animerts. However, 21

26 some of the richness and nuance of focus group data is inevitably lost in this compressed presentation. Undercover Lover Messages received Changes reported Booza brain Messages received Changes reported Sugar surprise Messages received Changes reported What s my risk Messages received Changes reported Condom wise Messages received More than one partner increases HIV risk and creates sexual networks. A single exclusive sexual partner reduces HIV risk. Use condoms every time with all partners. Mainly in area of awareness: the risk of HIV, importance of faithfulness, and importance of condom use. Condom use was seen as more workable than reducing partners. There is a link between alcohol, sex (particularly casual sex) and HIV. Alcohol increases the risk that you will fail to use condoms. You should assist friends when alcohol diminishes their judgment. It is best to abstain from sex when you have drunk too much. Mainly in the area of awareness and attitudes: heightened sense of risk and of importance of having condoms at all times, intention to assist friends to avoid exposure when drunk. Some behaviour change: intention to avoidavoiding shebeens. Some respondents said they were unable to change: a real man has multiple partners and drink makes it impossible to control behaviour. Transactional sex carries a high risk of HIV infection. People engage in transactional sex for material gain and status. Intergenerational sex can be risky in terms of HIV and exploitation of young women. Youth should preserve their independence and avoid trap of materialism. More caution about transactional sex. Increased awareness of risks of intergenerational sex. Intention to do without the material benets of transactional sex. Intention to use condoms without exception during transactional sex. Some participants indicated no change: some males felt it wasn t aimed at them and some females felt the material benets outweighed the risks. Having more than one sex partner increases your risk of HIV infection. Using condoms inconsistently won t protect you. Mainly reinforced existing knowledge about unsafe sex with multiple partners and increased intention to be more careful. Condoms are safe particularly Choice condoms. Condoms are quality-tested and one size ts all. 22

27 Changes reported Love words Messages received Changes reported Reinforcement of importance of consistent condom use. Trust in Choice condoms. Realisation that females should take responsibility for condom use. One should remain faithful to one s partner. Condoms must be used with all partners to protect against HIV. There are many reasons for people being unfaithful: sexual pleasure, material gain, peer pressure, loneliness, marital problems. Note: The irony of Love words was sometimes misunderstood. The message some got was that faithfulness meant protecting your partner by using condoms. Attitudinal change being less trustful of partner s behaviour. Overall conclusions Taken as a whole, participants reactions towards the Scrutinize campaign were overwhelmingly positive. The vast majority agreed that the campaign was educational, understandable and had a positive reported impact. As the animerts portrayed real life situations that participants could readily identify with, the campaign was deemed highly relevant, a Markdata report concluded. (Markdata, 2010) Audiences enjoyed the use of animation and the use of humour not simply for the sake of funniness but because humour facilitated the open discussion of HIV. Audiences appreciated the positive, up-beat tone. They felt that emotions could be read from the animated characters and that this helped to convey the messages. Animation did not detract from the realistic nature of the situations portrayed, appealed to all age groups and made it easier to portray potentially embarrassing topics (like having sex in toilets) and abstract concepts (like the sexual network). Markdata recommended that: Scrutinize should continue to focus on a youth audience (the year age range) but should consider targeting younger teenagers as well. The campaign should begin to include characters from minority South African population groups, particularly white people. The campaign should continue to use humour as a method of introducing sensitive matters and giving advice. The pace of animerts should be slowed down. Many respondents indicated that they struggled to understand the rapid delivery. The tempo should be relaxed particularly when delivering important facts and conveying technical information. Consideration should be given to building Victor s character so that he becomes a stronger model for appropriate behaviour. The accents and type of language used were acceptable and should basically be retained. 23

28 The use of more celebrities should be considered but they should be depicted through animations of themselves and not simply used to provide the voices of ctional characters. 7.3 Quantitative Impact evaluation (NCS 2009, 2012) The National Communication Survey (NCS) was designed to measure the impact of HIV communication programmes on behaviours that reduce the risk of HIV infection and on knowledge, beliefs and attitudes, social norms and other social inuences that in turn have an impact on the desired behaviours. While behaviour change may take time to achieve, progress in building knowledge and shaping personal attitudes may be reected earlier and may be a pre-condition for behaviour change. Figure 3 below illustrates how communication programmes may have indirect and direct effects on the behaviours that protect individuals against HIV and reduce the incidence of infection in populations. JHU CCP faculty members, Dr. D. Lawrence Kincaid and Dr. Maria Elena Figueroa, assisted by Dr. Mai Do of Tulane University, undertook specic analysis on the impact of Scrutinize on the major HIV behavioural variables and on related intervening variables using the National Communication Survey of 2012 (Kincaid DL and Figueroa ME, 2012). The impact assessment conducted by Dr. Kincaid in 2009 used data from the 2009 National Communication Survey. Multivariate causal attribution (MCA) analysis (Kincaid & Do, 2006; Babalola & Kincaid, 2009) was used to justify causal inference and estimate the impact of Scrutinize on HIV prevention behaviors. MCA analysis includes Structural Equation Modeling (SEM) to test the directions and causal pathways (direct and indirect effects) between communication exposure and dependent variables via multiple regression analysis. Dose response analysis was also conducted. Some of these results are shown below. Figure 3: A framework for evaluating the impact of HIV communication programmes ource: incaid D undated crutinie: hange V to Victory npublished 24

29 Scrutinize is the only initiative within the USAIDJHU HIV Communication Programme to have been evaluated by means of the NCS 2009 and NCS Both surveys drew a probability sample of more than respondents representative of the year age population from all nine provinces in South Africa. Audience exposure, retention and interpretation The 2009 survey found that 77% of males aged years and 76% of females in the same age range were exposed to Scrutinize. The campaign also reached large numbers of viewers outside of the target age group. (Figure 4) While the 2012 report presented the data slightly differently, the level of exposure seems quite similar. It established that 75% of males and 82% of females aged years were exposed to Scrutinize, as were 73% of males and 76% of females in the year age group. In the year age range, exposure was in the region of 62%. (Figure 5) Figure 4: Exposure to Scrutinize by age (NCS 2009) Figure 5: Exposure to Scrutinize by age and sex (NCS 2012) crutinie characters repre sent all wals of outh frican life 25

30 The surveys asked several questions related to Scrutinize and on the basis of these created a scale of unaided recall and understanding of the campaign. In 2009, the most clearly understood or readily recognised aspects of Scrutinize were: the meaning of scrutinize (69%), the concept of the sexual network (59%) and what the ninja represented (59%).The least understood or recognised aspects were: the concept of undercover HIV (the highly infectious window period) and the pay-off line in the alcohol and HIV animert: If the playa is too drunk... don t put him in the game. In 2012, respondents were more likely to be able to complete the main campaign slogans. Comprehension of key concepts, including the concept of the sexual network and the infectious period were similar between surveys. Items measuring understanding of meaning of messages Percent Correct meaning for Scrutinize Correct meaning for sex network animert Correct understanding of alcohol risk animert 36 NA 4. Correct understanding of the undercover HIV message Correct meaning given to the ninjas in the sexual network 50 NA 6. Correct identication of the small round gures as HIV Correct understanding of SA Map animert NA 33 Items measuring recall of specic content 8. Able to complete Flip HIV to HIVictory slogan Able to complete slogan Undercover lover can bring you HIV from another. 10. Able to complete slogan If the playa is too drunk don t put him in the game 11. Any response that Scrutinize means always use a condom NA 35 Total correct recall of one or more components 69% 72% 2009 sample sie 9728 euivalent to reached 2012 sample sie euivalent to reached not measured in survey The two surveys both undertook further exploration of audience understanding and interpretations of Scrutinize, but did so differently. In 2009, the NCS explored whether the primary audience (aged years) correctly construed messaging. It found that messaging on partner reduction was most likely to be correctly construed, with nearly 60% of respondents getting it right. Fewer than four 26

31 out of 10 were able to provide the correct meaning of the messages on HIV testing and condom use. (Figure 6) Figure 6: Correct message interpretation by primary audience (16-32 years)(ncs 2009) The NCS 2012 looked at the public s interpretation of the term scrutinize. The ndings are summarised in Table 4. List of Meanings by Spontaneous Mention Percent 1. See if your own sex behavior is risky Win the battle against HIV Get tested for HIV Get your sex partner tested for HIV Use condoms every time you have sex Only have one sexual partner at a time Too many sex partners can get you infected with HIV Don t have sex if you ve been drinking too much to use a condom Sugar daddies and mommies can give you HIV. 14 ultiple answers 6470 respondents who saw crutinie in last 12 months 27

32 By far the most common meaning provided for scrutinize was to get tested for HIV. This result was consistent with the strategic emphasis of Scrutinize in the period, which was to support government s mass testing campaign. The only other two meanings given by more than 40% of respondents concerned condom use and winning the battle against HIV. About one in ve respondents associated the word with messaging about the risk of multiple partners and the benets of monogamy. Impact assessment Both surveys focused on the impact of Scrutinize on HIV testing, condom use and sexual delity or partner reduction. The analysis of the role that intervening variables knowledge, attitudes, discussion and self-efcacy played in changing these specic risk-reduction behaviours was also conducted. Some of these results are shown below. Condom use The NCS 2009 showed that condom use among sexually active people in the year age group increased steadily in relation to their level of recall and understanding of Scrutinize. The effect was most notable among young men, with a 12 percentage point difference between those with no recall and those at the top of the scale. (Figure 7) The NCS 2009 data suggested that good recall and understanding of Scrutinize were less likely to translate into condom use among young women than among young men, as there was only a 6 percentage point difference in reported condom use between the least and best informed women. Figure 7: Condom use with any partner (last 12 months) by recall and understanding of Scrutinize and sex (NCS 2009) 28

33 Results of the analysis of the NCS 2012 showed that exposure to Scrutinize had an indirect impact on condom use through condom use attitudes and self-efcacy to use condoms. Attitudes and self-efcacy were gauged by respondents answers to a series of relevant questions. Positive attitudes to condom use and a high sense of efcacy were both associated with high self-reported levels of condom use. (Figures 8, 9 and 10) It should be noted that results shown in Figure 7 apply to the target audience aged years, while results shown in Figures 8, 9, and 10 refer to the sexually active population years old (those that reported having had sex in the last 12 months prior to the survey). This explains the considerable difference in the general level of condom use, which decreases with age. However, the ndings of both surveys point to Scrutinize having a positive impact on condom use after controlling for various potential confounders. Figure 8: Impact of exposure to scrutinize on attitudes favouring condom use (NCS 2012) Figure 9: Impact of Scrutinize on self-efcacy for condom use (NCS 2012) 29

34 Figure 10: Impact of favourable attitudes and self-efcacy on condom use (NCS 2012) HIV testing The NCS 2009 found a positive impact of recall and understanding of Scrutinize on various forms of discussion about HIV testing. Results (not shown) for the group aged years indicated that: The most common conversation on HIV testing was between friends; and those with the highest recall and understanding of Scrutinize were more likely to talk about testing (53%) than those with the lowest recall (35%). The percentage reporting disclosing their HIV status was also higher (43%) among those with the highest recall and understanding of Scrutinize compared to those with the lowest level of recall (31%). Recall and understanding of Scrutinize was also related to an increase in sex partners suggesting HIV testing to each other, but exposure to Scrutinize had a less powerful effect on this type of communication than on other forms of discussion. There was a 9 percent points difference on this behaviour (asking partner to test) between respondents who were least and most exposed to the campaign (33% and 42%, respectively). crutinie positively impacts discussion around V across target groups It should be noted that these forms of communication about HIV testing were not mutually exclusive. There were respondents who engaged in all three: talked to friends about testing, invited their partners to test and disclosed their own status. The NCS 2009 analysis conrmed the anticipated theoretical relationship between discussion on HIV testing and action in the form of undergoing an HIV test. The difference in HIV testing between those who had discussed the matter and those who had not ranged from 15% to 23%, depending on the type of discussion. (Figure 11) 30

35 Figure 11: Percent tested for HIV in last 12 months by type of discussion (NCS 2009) The percentage reporting HIV testing among young respondents (16-32 years old) in the NCS 2009 increased in direct relationship to the extent of face-to-face communication about testing and disclosure with partners and friends. Among those who had interacted with friends and invited a sexual partner to test and disclosed their HIV status (all 3 actions), 72% reported testing for HIV in the last 12 months prior to the survey (Figure 12). Figure 12: Testing for HIV in last 12 months by number of types of discussion on HIV testing (NCS 2009) 31

36 The NCS 2012 found that Scrutinize had a direct and an indirect effect on HIV testing after controlling for a set of potential confounders. The indirect effect worked through HIV test discussion and building self-efcacy for testing. Among respondents with the highest correct recall of Scrutinize, 51% reported testing for HIV in the last 12 months compared to 43% among those who could not recall correctly any aspect of Scrutinize. (Figure 13) Figure 13: Direct impact of Scrutinize on HIV testing (NCS 2012) In addition, NCS 2012 showed a dose response; as correct recall of Scrutinize increased, respondents were more likely to report that: They had discussed HIV testing with their sex partners. This ranged from 40% among respondents with zero recall of Scrutinize to 54% at the highest level of recall, a 14 percent point difference (gures not shown). They felt condent and able to undergo HIV testing. The range in this instance was 39% at the lowest level of exposure to 45% at the highest (gures not shown). xposure to crutinie leads to testing 32

37 Figure 14: Impact of discussion and self-efcacy on HIV testing in last year (NCS 2012) Figure 14 shows the impact of HIV discussion and of self-efcacy on HIV testing. The largest difference is with HIV discussion. After controlling for potential confounders, among those with any or high level of discussion of HIV testing, 63% reported testing for HIV in the last 12 months; this compares with only 32% among those with none or low levels of HIV testing discussion, There was also a more modest impact of self-efcacy on HIV testing. In sum, the last two National Communication Surveys both highlighted the Scrutinize campaign s effect on increasing discussion about HIV testing within close social networks and sexual relationships. Furthermore, they attest to the power of such discussion in determining whether individuals take an HIV test. Partner reduction and faithfulness to a single sex partner The NCS 2009 conrmed that exposure to Scrutinize had a signicant impact on the target audience s understanding that the HIV infection risk is decreased by reducing the number of sexual partners or remaining faithful to a single partner. (Figure 15) 33

38 Figure 15: Knowledge of partner reduction and/or faithfulness as a means of reducing HIV risk by exposure to Scrutinize (NCS 2009) Practice of sexual delity, in turn, was strongly associated with the knowledge that it reduced the risk of becoming infected with HIV. (Figure 16) Men who understood the benets of sexual delity (in terms of protection against HIV) were more likely to report that they were faithful to their partners than men who lacked this knowledge (58% and 37%, respectively). Among women, knowledge of the HIV risk posed by multiple partners and the self-reported practice of delity was less pronounced but still signicant. The overall impact of Scrutinize on multiple sexual partners showed that respondents who were able to give a correct interpretation of the Undercover Lover animert and the acute infectious period were less likely to report having multiple partners compared to those who could not understand and explain the meaning of this particular animert (gures not shown). 34

39 Figure 16: Practice of faithfulness by knowledge of it as method of HIV risk-reduction and sex (NCS 2009) The NCS 2012 also analysed Scrutinize s impact on developing understanding of the risk of multiple sex partners, shaping attitudes towards the practice and building self-ef- cacy to resist multiple sexual relationships. On average, about 60% of respondents spontaneously mentioned partner reduction as a method of limiting the risk of HIV infection. The percentage of respondents who grasped this varied signicantly, according to their level of exposure to Scrutinize. (Figure 17) Figure 17: Mention of partner reduction as method to prevent HIV infection by exposure to Scrutinize (NCS 2012) 35

40 In addition, the NCS 2012 found that after controlling for multiple potential confounders, exposure to Scrutinize resulted in: An increase in self-efcacy for resisting multiple partners. The analysis showed a difference of 8 percent points on reported self-efcacy between those with the lowest and highest exposure to Scrutinize (Figure 18). A weak and not signicant effect on attitudes that favoured the practice of multiple sex partners. The reason for this lack of effect may be that the MSP statements measured in the survey were not specically addressed by the animerts. Future campaigns should attempt to address these items given their inuence on behaviour as shown below. Figure 18: High level of self-efcacy for resisting MSP by exposure to Scrutinize (NCS 2012) The impact of attitudes and self-efcacy on the practice of having multiple sexual partners is reected in Figure

41 Figure 19: Impact of MSP attitude and self-efcacy to avoid MSP on having multiple partners in the last 12 months (NCS 2012) There is a clear tendency for people to act in accordance with their attitudes and sense of self-efcacy when it comes to the practice of multiple sexual partners (MSPs). People with low self-efcacy for resisting MSPs are about twice as likely to have multiple partners as those with high self-efcacy. And respondents who think favourably of MSPs are about twice as likely to have multiple partners as those who do not see the practice in a good light The Cost enet Analysis A cost analysis conducted by Dr Larry Kincaid on Scrutinize in 2012 indicated that Scrutinize reached over 18 million South Africans in 2009 between the ages of years of age. The cost to USAID per person reached was R1,03 (USD 0,14) and when taking into consideration the contribution of the media owners the total cost per person reached was R2,10 or USD 0,29. This indicates that evidence based mass media programmes are cost effective investments that can yield demonstrable returns on investments in relation to social and behavioural outcomes. 37

42 8 Concluding remarks Scrutinize achieved its strategic objectives in that it expanded knowledge of key methods of reducing HIV infection risk among young people (and beyond this group) and was associated with an increase in several of these practices, including HIV testing, condom use and faithfulness to a single sex partner. In essence, the quantitative evaluation results conrmed anecdotal evidence that young people had embraced Scrutinize. Examples cited anecdotally are young people adopting elements of Scrutinize language in their private conversations and students removing Scrutinize posters from public places to decorate their dormitory rooms. The hard evidence of the campaign s impact was signicant not only for JHHESA and its partners but for the wider HIV communication eld in South Africa. This is because it vindicated the choice to break with orthodoxy and utilise the somewhat confrontational parallel process model rather than the more gentle options pursued in the past. In effect, it expanded the theoretical foundations for HIV communication programmes. The NCS of 2009 and 2012 both showed Scrutinize s impact on behaviour in the areas of condom use, HIV testing and partner reduction. These self-reported behavioural gains were usually associated with positive changes in knowledge, attitudes and self-efcacy that were related to exposure to and comprehension of Scrutinize. Scrutinize was also an exercise in bringing peer communication to mass media platforms. By adopting popular culture in its animerts, Scrutinize essentially created a way to use television as a platform for communication among equals people of the same age, social class and culture. In many other HIV communication interventions there is a strong sense that unseen experts are teaching the public. Scrutinize managed to avoid even a hint of this didactic tone. opular culture taes to the screen There were two streams of research operating in support of Scrutinize: informal cultural research was undertaken by the creative team while JHHESA s research partner, CADRE, undertook more formal pre-testing. The Scrutinize experience suggests that where the creative tendency is to push the boundaries, the checks and balances of pre-testing become increasingly important. There needs to be an assurance that creativity in HIV campaigns is not an end in itself but remains in service of the stated behaviour change objectives The ability of Mediology to leverage huge amounts of value-add on the media spend for Scrutinize literally converted media companies into campaign partners that invested substantially in the initiative. Despite this, there was marked unevenness in the exposure that Scrutinize enjoyed from year to year great peaks and valleys in the number of media slots available. 38

43 Reach and recall of Scrutinize remained at a high level across the life of the campaign, despite the variations in actual volumes of advertising. Reach of 70 80% of the primary target audience can be regarded as impressive for any campaign. The reduction in levels of correct understanding of some messages during the period does correspond with a reduction in advertising and exposure levels during this period. The social mobilisation element of Scrutinize was relatively modest in terms of the size of total audience reached and the time frames for community outreach. Face-to-face communication is a high-cost, localised intervention and JHHESA is not alone in bowing to the practical and nancial constraints on up-scaling social mobilisation. The choice of university campuses as a focal point for Scrutinize s live, interactive element was smart because campuses are relatively self-contained communities and there is the prospect of intervening at several levels, as the social ecology model requires. The possibility exists that social mobilisation interventions will inuence individuals as well as impact on the social norms that prevail among students and the institutional policies that determine HIV policies on campus. Scrutinize was clearly memorable both in terms of its creative execution and its messages. It was not uncommon for focus group participants evaluating more recent JHHESA interventions, such as Brothers for Life and Intersexions, to draw relevant comparisons with Scrutinize. Various awards and accolades have come Scrutinize s way, including a multimedia award by Africomnet in 2011, shortlisting for an award at the Annecy animation festival in 2009, and a share in the Loerie Ubuntu Award made in 2011 to Levi s Red for Life initiative. But perhaps the praise that speaks loudest is the 2009 bronze Khuza Award made on the basis of votes from young South Africans aged eight to 22 years, the rst ever to be awarded to a youth social campaign in South Africa. crutinie resonates with young people 39