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«Suggested citation: Panday, S., Makiwane, M., Ranchod, C., & Letsoalo, T. (2009). Teenage pregnancy in South Africa - with a specific focus on ...»

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Nevertheless, data is available on the reach of national media campaigns, and their perceived usefulness, as well as estimations of their impact. The evaluation will focus on three of the largest national campaigns, loveLife, Soul City and Khomanani. The focus of each of these campaigns is outlined below.

Box 1: Description of three national HIV and AIDS campaigns in SA

Khomanani Khomanani was launched in 2001 as a government HIV and AIDS communication brand that operated for two years. It was re-launched in 2007 by the Department of Health with the aim of halving the incidence of HIV infections by 2011 and mitigating the impact of AIDS on individuals, families and communities. The campaign focuses on accelerated HIV and AIDS prevention; care, treatment and support; nutrition, health promotion and TB.

The programme targets youth of school going-age. It sought to mobilize individuals to participate in caring communities that together take on the challenges posed by STIs, HIV and AIDS and TB (GCIS, 2003). It encourages young people to delay sex and for those who are sexually active to adopt safe sexual practices (Cullinan, 2002). The programmes also focused on the risks of transactional sex. It distributes its message via TV and radio commercials, public service announcements, print media and community outreach programmes (SAGI, 2005). Khomanani is guided by the HIV and AIDS and STIs Strategic Plan for South Africa. It uses a behavioral change framework that seeks to foster changes in sexual behaviour through a five-step process of knowledge, approval, intention, practice and advocacy (GCIS, 2003).

Soul City Soul City is the longest running HIV and AIDS awareness and prevention programme in SA. It was established as an NGO in 1992 and targets teenagers and adults as well as children aged 8-12 through its two main brands, Soul City and Soul Buddyz respectively. Soul City uses its edutainment model to inform programming. Edutainment integrates social issues into accessible, popular and high-quality entertainment formats, based on a thorough research process (Soul City 2009a). Although its main medium is TV and radio drama, it also uses community radio talk shows, TV and radio commercials, the print media and as well as outreach events such as community dialogues to spread its message (oneLove, 2008). While the main thrust of Soul City is on HIV and AIDS and sexual behaviour, it also seeks to improve people’s health and quality of life in general by addressing issues such as gender-based violence, substance abuse and small business development (Soul City, 2009a).

Integral to Soul City’s approach towards programming is extensive consultation with both civil society as well as experts in the field (Soul City, 2009b). Soul City combines a number of intervention models and theories that focus beyond individual behaviour. Soul City submits to WHO’s Ottawa Charter that theorizes that an individual’s health is affected by a range of cross-cutting factors. This involves integrating the creation of an enabling environment with public health policy, community action, developing personal skills and health promotion. Behavior change theories such as Bandura’s Social Learning theory (Bandura, 1986) and John Hopkins University’s model of Steps to Behaviour Change also inform Soul City’s mass media programming.

93 Teenage pregnancy in South Africa - with a specific focus on school-going learners loveLife loveLife was launched in 1999 as a major South African national HIV prevention programme targeting youth aged 12-17 (loveLife, 2009). It works with approximately 130 community-based organisations, several nongovernmental organisations and government. loveLife developed a strong youth development brand that young people can identify with. The brand was used to raise discussions about sex and expose the link between sex and HIV and AIDS (Harrison, 2008a). The main goal of loveLife is to reverse the HIV epidemic among young people, while concomitantly addressing teenage pregnancy and other sexually transmitted infections (loveLife, 2009). It also seeks to address issues such as sexual coercion, imbalanced gender roles, and encourages family discussions about sex. loveLife’s theoretical framework of behaviour change is informed by behavioural theories such as diffusion of innovations, ecological theory and the theory of reasoned action (Azjen and Fishbein, 1980; Rogers, 2003; Waldo and Coates, 2000). It focuses on creating change through social networks, opinion leaders and change agents (Pettifor et al., 2007).

loveLife uses the combination of mass media and community outreach programmes to encourage community participation which will, in turn, engender positive living (Harrison, 2008). Mass media approaches include TV and radio commercials, talk shows, outdoor media, print media and face-to-face services provided in the 11 official languages of the country. It also runs a helpline for both youth (thethajunction) and parents to access sexual health information. loveLife re-packages its message through community-level campaigns that makes use of mentors and peer educators. About 1200 national corps (groundBREAKERS) aged 18-25 years and 5000 volunteer peer motivators (‘impintshis’) lead the loveLife’s HIV prevention education and youth mobilization programme into communities including about 4 200 schools.

To strengthen its community outreach arm, loveLife also provides youth friendly service in collaboration with about 350 government clinics nationally. It has also established 17 non-clinical youth centres known as Y-centres throughout the country. These centres are inter-sectoral in that they provide youth with sexual health education, and accessible adolescent health services in a non-clinical environment as well as other opportunities for youth development such as computer training and recreational activities.

In collaboration with the Department of Sport and Recreation, loveLife conducts the loveLife Games - an inter-school sport and lifestyle development initiative, which attracts over 250 000 learners and about 2000 teachers annually (loveLife, 2009). The Games promote HIV prevention and health living, self motivation and personal achievement (Harrison, 2008). In addition, loveLife has trained a network of 500 grandmothers

- known as goGogetters, to assist with HIV prevention among 6000 orphaned and vulnerable children.

Programme focal areas include assisting orphans to stay in school and gain access to government support services such as social grants, preventing sexual abuse, and maintaining their general wellbeing (loveLife, 2009).

There are relatively high levels of knowledge of all three programmes among 15-24 year olds, although Khomanani lags behind (See Figure 15). To achieve high-frequency and high-intensity media coverage, however, awareness should be around the 80% mark (Harrison, 2008a). Both Soul City and loveLife have been achieving these levels of penetration over the past five years in this age group.

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Figure 13: Proportion of 15-24 year olds who know of Soul City, loveLife and Khomanani Knowledge of HIV prevention programmes among 15-24 yr olds

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60 50 40 30 20 10 0 2003 2005 2006

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Source: Harrison, 2008a Young people in SA place a great deal of trust in national HIV campaigns as a source of information. Over four fifths of youth (85%) trust national campaigns as a source of information about HIV, surpassed only by doctors/scientists (87%) (Kaiser Family Foundation & SABC, 2006). Equally high numbers (83%) perceive national HIV campaigns to be an effective source of teaching about HIV. The 2005 SABSMM survey (Shisana et al., 2005) measured the perceived usefulness of HIV campaigns for HIV information. All three campaigns (Soul City – 95%; Khomanani – 80%; loveLife – 91%) received a high level of endorsement in terms of their perceived usefulness by young people.

While specific interventions have attempted to demonstrate their impact on behaviour, more robust assessment of impact is likely to be gauged from a cumulative effect of exposure to multi-media programmes. In 2006, the first national HIV and AIDS communication survey was undertaken in SA. Secondary analysis of the data was conducted to estimate the impact of eight national communication programmes involving 19 communication sub-components on several HIV-related outcomes (Kincaid et al., 2008). The findings suggest substantial direct effects on 13 HIV-related outcomes based on exposure to various national communication strategies, although these findings are not specified to youth. These effects are evident on among others condom use, self-efficacy to use condoms, communication with friends and partners about HIV testing and faithfulness to partners (see Table 19). The size of the effect varies with increasing levels of exposure to communication programmes indicated by the range of the impact in Table 19. For example, while 38% of participants who were not exposed to any media programmes used a condom to prevent HIV, 56% who were exposed to 15 or more programmes used a condom. The findings provide support for increased coverage and intensity of media programmes (Kincaid et al., 2008; Harrison, 2008a), although the upper limit of the range of impact suggests that there is a threshold to which cumulative exposure can have an impact on behaviour. Hence media programmes, while effective in changing a range of behaviours, need to be supported by other intervention strategies.

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Community-based interventions Because of the somewhat limited benefits of single interventions in discrete settings, and the increased recognition of multiple sources of risk and protective factors, over the past two decades, there has been an increased recognition of the need to focus on multi-component community-based activities as a support to institutional interventions (Kirby, 2007; NRC & IOM, 2005). These use various combinations of school and health-based interventions, community awareness raising including media type interventions and, in some cases, working with youth organisations. A review of six community-wide interventions in the US showed mixed results. Kirby (2007) indicated that firm conclusions could not be drawn because of the generally weaker design of community interventions. While the fear that community-based interventions will increase sexual activity has not manifest, there were positive indications from four studies that such interventions can delay initiation of sex, increase condom use and lower pregnancy or birth rates at a community-wide level.

An evaluation of 22 community-based interventions focusing on young people in developing countries also indicated that the lack of rigour in the evaluation of interventions severely constrained the conclusions that could be reached (Maticka-Tyndale & Brouillard-Coyle, 2006). In this review, 4 types of community-based

programmes were reviewed:

• Programmes targeting youth that were delivered through youth organisations or youth centres;

• Programmes targeting youth that built specific infrastructure for the interventions;

• Programmes targeting community members in general and delivered through support networks; and

• Programmes targeting whole communities delivered through community-wide events.

Interventions were designed to increase knowledge related to HIV, build skills such as condom use self-efficacy, change sexual behaviour as well as raise awareness and shift community norms. None of the studies reviewed

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produced strong evidence of positive effects on behaviour. Most studies produced mixed results and many were too poorly designed to reach conclusions about their effects. The strongest evidence for positive effects on knowledge, skills, age of sexual debut or condom use came from 10 studies that targeted youth through youth organisations. However, no effects were reported on the incidence or frequency of sexual activity or on multiple partnerships. While the review recommends delivery of such interventions at scale, it cautions that they need to be supported by rigorous monitoring of operational processes and evaluation of impact. Most of the interventions using this design were delivered by peer educators. To ensure the successful application of this delivery format, the review recommends using established criteria to recruit peer educators and providing training and ongoing monitoring and support throughout the programme. The weak design, limited number and short evaluation period of the other modalities, limit recommendations about their wide-scale implementation, although there is some evidence for their positive effects.

Participation in community-level activities is generally low among young people in SA. The 2005 SABSMM survey (Shisana et al., 2005) showed that while a quarter (25.7%) of adults aged 25-49 years participated in community meetings, only about a sixth (16%) of youth aged 15-24 years attended such meetings. Although loveLife is often identified by its prominent multimedia interventions, it has an equally strong community-level presence, described in Box 1 above. However, only about a third (34%) of young people who participated in the 2003 RHRU survey reported participation in loveLife’s community–based activities (Pettifor et al., 2004).

Although community-based activities focused on HIV are not perceived by young people to be as effective as teachings learnt from health workers or national campaigns (SABC & Kaiser Foundation, 2006), analysis of cross-sectional data shows that participation in loveLife activities significantly reduces the odds of being HIV positive among both males (0.6) and females (0.61). The analysis controlled for a number of factors including awareness of two different national HIV prevention campaigns (Pettifor et al., 2005). While cross-sectional data can never prove attribution (Harrison, 2008a) and analyses have not taken into account the effects of exposure to multiple HIV and AIDS programmes taking place in SA (Jewkes, 2006; Parker & Colvin, 2006), the analysis does provide some indication of the impact of loveLife on HIV risk. In addition, participation in loveLife programmes has also been associated with greater self-motivation, more interpersonal communication about HIV, high condom use and greater likelihood of testing (Harrison, 2008a).

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