Implementation Period: June - December 2014
"The qualitative data from listening clubs showed that youth believe good communication with their parents has a big influence on their behaviours and can help them to make healthier and more informed decisions."
This is one finding from the final report of Shuga, an evidence-based and participatory behaviour change communication (BBC) edutainment radio drama designed to increase demand for HIV testing and counselling (HTC) and condom use among sexually active youth aged 15-24 years. The report focuses on the 12-episode drama series as it was aired on 10 community radio stations and Clouds FM (the national commercial radio station) in Tanzania from June-December 2014. (See Related Summaries below for full details.) The United Nations Children's Fund (UNICEF) Tanzania worked in collaboration with the Tanzania Commission for AIDS (TACAIDS), the United Nations Educational, Scientific and Cultural Organization (UNESCO), Ministry of Health and Social Welfare (MOHSW), and civil society organisation (CSO) partners engaged in behaviour change communication (BCC).
UNESCO led a media capacity building programme for the community radio stations, part of the Tanzania Network of Community Radios, to enhance outreach and participation of young people and to provide relevant localised information to address unique contexts and challenges faced by youth in a culturally appropriate and gender-sensitive manner. Approximately 4 million young people were reached by the Shuga radio serial drama.
A pre- and post-Shuga airing survey was administered through mobile phone interviews (known as T-Watoto) in randomly selected households in Mbeya, Iringa, and Njombe regions. There was also a pre- and post-questionnaire for the radio listening clubs, as well as collection of qualitative feedback on each of the episode from the members of radio listening clubs and an SMS (text messaging) survey among subscribers of the Shuga short code.
The T-Watoto findings showed that Shuga contributed to creating more awareness and knowledge of, and demand for, HTC among youth. The survey had a sample size of 1,086 youth 15-24 years at baseline and 1,012 at endline. Results illustrated a notable increase on HTC awareness among adolescents aged 15-17, from 74% at baseline in June 2014 to 84% in December 2014. In terms of reported HTC, all districts except Mbarali showed that the number of respondents aged 15-24 who reported testing for HIV in the past 12 months increased between baseline and endline: Mufindi (50% to 73%), Njombe Rural (45% to 68%) and Makete (52% to 67%), Mbeya Rural (27% to 46%) and Iringa Rural (40% to 46%). Overall, the biggest increase in reported HTC was from 58% to 79% among young people of age 23-24; for those of age 15-17, the increase was from 22% to 34%.
Among the listening clubs, 295 young people conducted the pre-test and 475 the post-test. Unfortunately, there were quality issues with the pre-test questionnaire and, therefore, the analysis was carried out only using post-test data. Results showed that only 69% of the respondents agreed that condoms can prevent HIV, while 11% disagreed and 20% did not know.
Almost 2,000 self-subscribed SMS respondents aged 15-24 from 23 regions who had listened to Shuga radio serial drama initiated a survey, but only 712 (497 males and 215 females) completed it. Among those who completed the survey, 91% of SMS respondents aged 15-24 years believed condoms can prevent pregnancy, yet only 80% of respondents believed they prevent sexually transmitted infections (STIs), with no significant difference between male and female respondents. And only 71% of respondents believed that condoms can prevent HIV, with females less likely to believe this than males. Taken together, the results point to the need to shorten the SMS surveys to improve response rate, as well as to better understand, through qualitative approaches, why the belief that condoms prevent pregnancy is stronger than that of condoms preventing STIs and HIV.
With respect to qualitative findings, the listening clubs used the Shuga discussion guide to discuss the issues that were presented on each particular episode. The group leader made the summary, completed the field activity report form, and submitted it to the responsible organisation or the community radio station. Findings, in summary: Multiple partnership and alcohol abuse often catalysed by peer pressure were the risky behaviours most frequently mentioned among the young people in the listening clubs. They have indicated sexual relationships with much older adults as a growing practice in the community that should not be accepted. The young people also felt that, for several reasons, they are not adequately equipped to avoid risk behaviours that expose them to the risk of sexual abuse and HIV infection. Some of these are:
- Limited parental engagement: the young people acknowledged the role of parents as central in guiding children and adolescents. However, open discussion about sensitive issues like sexual relations is almost impossible among most families. They have also indicated that some parents are not often engaged to follow up their children when they are outside of their homes. Most importantly, they highlighted that some parents themselves do not know about HIV prevention, and how to engage with their children. The young people desperately wanted to know how to be close to their parents and openly talk about the things that concern them. They have strongly suggested Shuga to also target parents and communities as they are the ones nurturing the young.
- Low level of life skills education in relation to sexual reproductive health and HIV prevention: The need for life skills education is the second most frequently mentioned areas next to parental engagement. On several instances, they asked several basic life skills questions related to; the right age to be sexually active, how to talk to parents, how to seek and weigh advice, how a person can live with HIV, how to use condom correctly. They have also raised critical questions related to sexual violence, which they acknowledged is very common particularly for girls looking for jobs, as well as in the work place as featured in the drama. The young people asked what steps to take in the case of sexual violence, where to report, how the law [can] assist them and what options are there if the law fails to take action.
- Low level of condom use: The other repeatedly raised issue was limited knowledge and skills among young people on how to use condoms consistently and correctly. Most importantly they mentioned misconceptions that hinder young people from using condoms, including: condoms reduce pleasure, erode trust between partners, and it is an immoral practice. Young people also highlighted that during unprotected sex, girls are more concerned about the immediate risk of unwanted pregnancy than HIV infection. They stressed the need to strengthen education on consistent and correct use of condoms targeting young people, targeting the misconceptions.
- Barriers to HTC: The young people in the listener clubs acknowledged the importance of testing for HIV, however they strongly indicated fear of finding out the results, and being stigmatized if they turn out positive as major barriers to young people to utilize the service. They have also indicated the need for quality and youth friendly HTC services.
- Seeking and weighing advice from trusted peers and adults: The young people mentioned that young people get all kinds of advice from different sources. However, they stressed the need for open discussion with trusted friends, relatives and families. They however indicated that being wise in choosing the good advice, and taking responsibility for the decisions they make in the end as critical factors in making healthy choices.
Challenges related to the monitoring and evaluation process itself that are outlined include: Quality data collection was a challenge, particularly in listening club pre-post tests and the SMS survey (where questions were automated). Also, inconsistency of membership within listening clubs led to variation among the listeners in some of the clubs, with members not following the whole series for reasons including inconvenient broadcast timing. Furthermore, the T-Watoto mobile phone survey focused only on HTC issues, given that sexual experience and condom use were sensitive issues to ask a youth respondent over the phone. There were also difficulties in accessing national data on HTC per region/district, adequately disaggregated by age and gender, so as to be able to compare the HTC trend of the young people at the health facilities before and after airing Shuga radio serial drama.
That said: "There is high demand among the community radios for continued broadcasting of the Shuga program, including for a second phase. One community radio (Kitulo FM in Njombe) re-broadcasted the program at the request of the young people and a national private radio station Radio 5 aired the Shuga radio serial drama for free being part of the institution social responsibility to the community."
The organisers stress that multisectoral support is needed to design successful BCC programmes. "Much of the success of Shuga radio is because of the support obtained from key partners at community level, the Shuga Advisory Committee (with strong leadership from TACAIDS) and partnership with UNESCO. Moreover, within UNICEF planning, monitoring and evaluation colleagues played a big role in supporting the M&E design and data analysis, and communication advocacy and partnership colleagues supported in Facebook posts and linking Shuga radio serial drama to Radio 5."
The report concludes that, although "there is a challenge of attribution of a particular social behaviour change communication activities to HTC outcomes, use of multiple monitoring and evaluation approaches generated the assertion that radio was among the top three sources of information for young people about HTC (along with health workers and teachers) and suggested that more efforts should focus on adolescents, who were less likely than young adults to be aware about HTC and to report being HIV tested."
Emails from Alison Jenkins to The Communication Initiative on October 29 2015 and November 6 2015.