Evaluating the Intensity of Exposure to MTV Shuga, an Edutainment Program for HIV Prevention: Cross-Sectional Study in Eastern Cape, South Africa

"...greater engagement with a youth-focused edutainment campaign can improve HIV testing and prevention options in a setting and population with high need."



Over the course of the HIV/AIDS epidemic, edutainment and mass media campaigns have played an important role in health promotion. MTV Shuga is an edutainment campaign designed to equip young people with knowledge, motivation, and informed choices to protect themselves from HIV infection. From 2019 to 2020, 10 episodes of a new dramatic series, MTV Shuga "Down South 2" (DS2), were broadcast via television and the internet, alongside complementary media activities. This study sought to investigate whether the intensity of DS2 exposure was linked with positive HIV prevention outcomes in a setting with high HIV prevalence and relatively low levels of HIV testing.



Shuga incorporates what are meant to be compelling characters and storylines to disseminate messages on HIV prevention through a series of parallel but interlinked storylines, which are offered over multiple episodes and media channels. Specifically, DS2 storylines largely revolve around characters who have recently left high school and are navigating life and the challenges that many young people face, including financial hardship, family conflict, and sexual relationships. (Detailed descriptions of example storylines for DS2 have been documented previously; see Related Summaries, below.) Producers of DS2 conducted formative research through focus group discussions with young people to develop and validate the content, storylines, character development, and scripts, as they did for all previous MTV Shuga series. DS2 episodes were broadcast via television and the internet alongside complementary media and offline activities, which included a documentary, peer-led discussions, DS2 graphic novels, and community-based viewing events.



The researchers conducted a web-based survey of participants aged 15 to 24 years in South Africa in 2020. The survey was promoted via social media platforms of schools, universities, and communities in Eastern Cape, South Africa. The primary exposure of interest was the intensity of exposure to DS2, measured by the number of episodes of DS2 watched on the television or the internet or listened to on the radio (out of 10 episodes). Individuals who had not watched or listened to any DS2 episode were classified according to other MTV Shuga content they had accessed. The researchers estimated associations between the intensity of DS2 exposure and HIV-related outcomes, including knowledge of HIV status, awareness of HIV self-testing (HIVST) and pre-exposure prophylaxis (PrEP), uptake of HIVST, and demand for HIVST and PrEP, adjusting for potential confounders using multivariable logistic regression.



Among the 3,431 survey participants, 827 (24.1%) were exposed to DS2. Specifically, 18.1% (622/3,431) watched or listened to only 1 DS2 episode, and 2.4% (82/3431), 1.7% (58/3431), and 1.8% (62/3431) watched or listened to 2-4, 5-7, and 8-10 DS2 episodes, respectively. Increasing the exposure to DS2 was associated with improvements in most outcomes. Exposure to multiple episodes (e.g., 2-4, 5-7, and 8-10) was associated with successively higher odds of knowledge of one's HIV status, awareness of PrEP and HIVST, and uptake of HIVST compared with no MTV Shuga exposure, albeit with statistical uncertainty around some estimates. Examples of regression results include:

• Knowledge of HIV status was 28.1% (431/1,535) among those not exposed to any MTV Shuga content and highest among those who had watched or listened to 8-10 DS2 episodes (45/53, 84.9%). In the adjusted analysis, increasing DS2 exposure was associated with increasing knowledge of HIV status. Compared with individuals not exposed to any MTV Shuga content, the adjusted odds ratios (aORs) for those who had watched or listened to 1 DS2 episode, 2-4 DS2 episodes, 5-7 DS2 episodes, and 8-10 DS2 episodes were 2.65 (95% confidence interval (CI) 2.01-3.49), 3.92 (95% CI 2.05-7.48), 3.82 (95% CI 1.84-7.91), and 5.72 (95% CI 2.46-13.32), respectively.
• Increasing DS2 exposure was associated with increased awareness of PrEP in the adjusted analysis: for example, 47.2% (215/456) of those who had watched or listened to only 1 DS2 episode versus 17.1% (251/1469) of those not exposed to any MTV Shuga content (aOR 2.38, 95% CI 1.83-3.09) and 76% (38/50) of those who had watched or listened to 8-10 episodes versus 17.1% (251/1,469) of those who were not exposed to any MTV Shuga content (aOR 7.25, 95% CI 3.56-14.79).
• Regarding lifetime awareness of HIVST (ever heard of HIVST), proportions ranged from 18.8% (284/1,509) among those who were not exposed to any MTV Shuga content to 56.4% (270/479) among those who had watched or listened to only 1 DS2 episode and to 75% (39/52) among those who had watched or listened to 8-10 episodes. In the adjusted analysis, those exposed to 2-4, 5-7, or 8-10 episodes of DS2 had >5 times higher odds of being aware of HIVST compared with those not exposed to any MTV Shuga content.
• Lifetime use of HIVST was 26.4% (125/474) among those who had watched or listened to only 1 DS2 episode versus 7.8% (115/1,483) among those not exposed to any MTV Shuga content (aOR 2.49, 95% CI 1.83-3.38), 32.8% (21/64) among those who had watched or listened to 2-4 DS2 episodes (aOR 3.93, 95% CI 2.16-7.15), 35.2% (19/54) among those who had watched or listened to 5-7 episodes (aOR 4.74, 95% CI 2.50-9.02), and 40% (21/53) among those who watched or listened to 8-10 episodes (aOR 4.57, 95% CI 2.46-8.50).

Interest in using HIVST or PrEP was high overall (>80%), with no measurable differences by DS2 intensity. That is, the researchers found no evidence of an effect of DS2 exposure intensity on the interest in using HIVST or PrEP (a proxy for demand), which was already high in the study population.



Regarding knowledge of HIV status, awareness of PrEP and HIVST, and lifetime uptake of HIVST, there was evidence that exposure to other forms of MTV Shuga content (other than the DS2 dramatic series) was beneficial, compared with no exposure to MTV Shuga content. For instance, knowledge of HIV status was 74.4% (215/289; aOR 2.52, 95% CI 1.78-3.56) among those who had watched DS1 and 63% (182/289; aOR 1.84, 95% CI 1.33-2.54) among those who had accessed other MTV formats compared with 28.1% (431/1535) among those with no exposure to MTV Shuga content.



In the study sample, repeated exposure to DS2 episodes was mainly through television or the internet. The intensity of DS2 exposure did not differ significantly by how young people accessed DS2 (P=.46), although higher proportions of repeat viewers watched or listened to DS2 with a parent than those who watched or listened to 1 DS2 episode. However, with regard to how young people access DS2, findings indicate a mix of preferences, with the majority watching or listening to DS2 alone or with peers (e.g., friends or partners) and less so with siblings and parents.



Reflecting on the findings, the researchers suggest that more exposure to DS2 may facilitate increased levels of narrative engagement and, in turn, helps the viewers or listeners to retain a greater amount of relevant content compared with someone with little or no exposure - particularly when the audience is interested in finding out what eventually happens to the characters, often facilitated by the immersive nature of the DS2 series. "The high identification with the DS2 characters and storylines likely enhanced the effect of watching DS2. The larger effects among those who watched or listened to multiple DS2 episodes suggest the potential benefits of viewing dramas as a whole rather than as a series of parallel storylines..."



Notably, only 6% (205/3,431) of the study respondents had accessed ≥2 DS2 episodes despite their availability on multiple media platforms (e.g., YouTube, South African Broadcasting Corporation, local radio stations, and the MTV Shuga website) and the sample's high engagement with media (3,101/3,431 (90.4%) watching television, listening to the radio, or watching YouTube at least once a week). The low exposure to multiple episodes may reflect various issues inherent in engaging a relatively young population (aged <25 years). For instance, young viewers or listeners often have no control over when episodes are aired on television or radio channels, and they might actively avoid watching or listening to MTV Shuga episodes with parents or older siblings because they feared that it would be awkward.

"These findings point toward the need to ensure privacy and nonjudgmental spaces in the delivery of campaigns targeted to young populations." For example, it might be worth finding ways to facilitate and increase offline viewing of DS2 episodes. In particular, peer education and school education programmes may be good complementary options, provided they take into account young people's preferences when designing and delivering these campaigns.



In conclusion, this study found that "increasing DS2 exposure was associated with increasing knowledge of HIV status, awareness of PrEP, and use of HIVST. This is consistent with a dose-response effect and supports the plausibility of a causal association between DS2 and HIV prevention outcomes among young audiences. Overall, relatively few participants viewed multiple episodes of DS2, and supporting young people to view or listen to more episodes of the DS2 campaign can yield benefits for more young people."