The Impact of Brothers for Life on the uptake of Medical Male Circumcision

Lusanda N MahlaselaCentre for Communication Impact

Contents

1background and objectives

2key limitations

main findings3 4

the final say

Background• Brothers for Life is a South African national campaign that promotes

the health and wellbeing of men aged 16-34 • Launched in August 2009• Focus on HIV prevention, medical male circumcision (MMC) and

sexual and gender-based violence

To measure the impact that Brothers for Life campaign, in particular the latest MMC campaign featuring women at a hair salon (Salon advert) has had on awareness and behaviour relating to the uptake of medical male circumcision in South Africa

Objectives of the study

• The Brothers for Life Survey formed part of the Khayabus omnibus survey conducted by Ipsos

• The questions were developed by CCI and the questionnaire was designed by Ipsos• In-home face-to-face Computed Assisted Personal Interview method was used • A sample of 3,617 nationally representative interviews was conducted. This was then

weighted to the entire adult South African population (15 years of age and older) • Interviews were conducted in English, Afrikaans, isiZulu, isiXhosa, Setswana, Sepedi and

Sesotho as per respondent choice • Fieldwork was conducted from the 17th September to 19th of October 2015• Ethics approval was granted by the Human Sciences Research Council Ethics Committee

Methodology

Key limitations• Due to the programme design, the reach of certain components of the campaign (e.g.

radio, out-of-home media and social mobilisation) was more concentrated in some provinces: KwaZulu-Natal, Gauteng, Limpopo, Mpumalanga and Free State

• The national broadcaster placed an after 9pm restriction on the Salon advert because a condom was shown in the advert

• Accurately measuring the efficacy of a campaign is a challenge due to multiple factors that influence behavioural change. An exposure variable to measure the level of impact (dose response) of the campaign on knowledge, attitudes, norms and behaviour was therefore created

• Refusal rates- due to sensitive and personal nature of some of the questions, some respondents refused to answer those questions. Some scores were therefore “re-percentaged” to exclude refusals. Refusal rates are lower for those with higher exposure to the campaign

Measuring campaign exposure: the exposure variable• An exposure variable was created in order to measure the dose response to the

campaign against attitudinal and behavioural outcomes. The following six variables were used to create this variable:

Seen logo (unaided recall)Campaign recognition (unaided recall)Recall of meaning of B4L (aided recall)Recall of Zing advert (aided recall)Meaning of the term “upgrade” (aided recall)Identification of the main message (aided recall)

Measuring campaign exposure: the exposure variable (cont’d)The exposure variable was used to segment the population according to level of exposure to the six individual variables.

This variable can then be used measure the impact of the campaign on certain behaviours

None (0 items) Some (1-2 items)

Medium (3-4 items)

High (5-6 items)

Total None Some Medium High0

20

40

60

80

49

34

43

5661

Level of exposure

HIV

testi

ng

%

Main findings

Condom use: first sex vs last sex

Total Male Female 15-17 yrs* 18-24 yrs 25-34 yrs 35-49 yrs 50+ GP WC KZN MP FS NW LP EC NC0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

53

39

46

53

63

42

48

55

62

38

42

58

62

% Yes*Total

None

Some

Medium

High

None

Some

Medium

High

None

Some

Medium

High

63.13

11.227548963301

9.67356672104321

9.86837437923381

32.3614190955975

12.7663429617696

10.4705926737299

8.80533029446536

31.0886432292107

8.23583291691181

10.3223802800506

14.3829438775254

30.1897520846877

% Yes*

15-30 year olds

*Re-percentaged to exclude refused/do not know

Condom use is consistently higher among those with a higher exposure level to the B4L and ZAZI campaigns.

QI5. Did you use a condom the LAST time you had sex? QI3. Did you use a condom the FIRST time you had sex?

Medical Male Circumcision campaign

Males: Are you circumcised?

Yes56%No

24%

Refused20%

N=18,139(n=1,801)OMO

Yes50%

No10%

Do not have a partner20%

Refused20%

Females : Is your partner circumcised?

N=19,525(n=1,816)OMO

Total

No exposure

Some exposure

Medium exposure

High exposure

70

58

61

69

82

B4L*

% Yes*

QI19.1. Are you circumcised? Male respondentsQI19.2. Do you know if your partner is circumcised? Female respondents

Circumcision increases with exposure to the Brothers for Life campaign

B4L Exposure Circumcision Date

None Some Medium High Last 3 years ˃3 yrs

n= 524 378 397 1210 167 760N= 6,117 4,006 4,021 11,720 1,646 7,506

66% 74% 76% 77% 79% 75%

67% 67% 68% 76% 72% 74%

50% 60% 58% 62% 59% 60%

21% 36% 25% 31% 33% 33%

20% 27% 21% 28% 33% 33%

12% 6% 4% 2% 2% 4%

2% 0% 0% 0% 1% 2%

*Caution: Small base size

When it comes to the main benefits of circumcision, i.e. reducing the risk of HIV and STI infection, South Africans with a higher level of exposure to the B4L campaign are more likely to say

Reduce the risk of getting HIV

Reduce the risk of getting STIs

Keeps men clean and healthy

Makes sex more pleasurable for him

Makes sex more pleasurable for women

It is our culture/tradition/custom/belief

Indicates that you are a mature young man/real man / to become a man

74

71

58

29

25

5

1

%

N=25,864(n=2,509)MMP

QI17. Why do you think men should get circumcised? Respondents who think men should get circumcised

There has been a generational shift from traditional to medical circumcisions, as is evident from the age profiles of circumcised men.

A traditional surgeon/circumciser

A religious practitioner

A government clinic

A private doctor

A private clinic

Other

Refused/Do not know

38

7

34

9

8

1

3

%

Total GP WC KZN MP FS NW LP EC NC

n= 1,016 343 98 150 83 55 22* 106 137 22*

N= 10,079 2,529 922 1,644 1,048 608 355 1,369 1,352 250

Medical 51% 59% 48% 72% 51% 59% 62% 39% 9% 97%

Traditional 45% 34% 45% 24% 46% 41% 38% 59% 87% 3%

Traditional 45%M

edical 51%

Total 15-17 years

18-24 years

25-34 years

35-49 years 50+

n= 1,016 28* 243 336 279 127

N= 10,079 267 2,650 2,647 2,573 1,923

Medical 51% 96% 63% 56% 42% 33%

Traditional 45% 4% 34% 40% 54% 60%

N=10,079(n=1,016)OMO

QI23. Where did you get circumcised? Respondents who have been circumcised *Caution: Small base size

…Yes

Is there a significant difference in the awareness and behaviours of circumcised vs. uncircumcised men? The answer is Yes!

There is a strong positive correlation between being circumcised, getting tested for HIV and condom use

Circumcised?

…No

HIV test Yes: 50% No:46%

Condom First Sex

Yes: 53% No: 42%

Condom Last Sex

Yes: 59% No: 36%

HIV test Yes: 35% No:62%

Condom First Sex

Yes: 29% No: 66%

Condom Last Sex

Yes: 35% No: 59%

QI19.1. Are you circumcised? Male respondents

Yes39%

No 51%

Refused/Don't know10%

Of those who had seen the advert, the vast majority understood the statement “get the upgrade that counts” to refer to circumcise and condomise

Seen the advert?

Circumcise only16%

Circumcise and condomise77%

Refused/Don’t know

6%

Women should talk to men about MMC

Men should get circumcised

Women should talk to other women about encouraging their partners to get circumcised.

Men who are circumcised should still use condoms

Women should support their men when they get circumcised

Circumcision means getting better sex

Healthy relationship

People should wait for six weeks before having sex

Refused/Do not know

50

50

45

40

38

33

27

18

2

%

Get the upgrade that counts

N=37,664(n=3,617)OMO

N=14,572(n=1,494)OMO

N=14,572(n=1,494)MMP

Main message of the advert

QJ5. In the last 12 months have you seen this picture before?QJ6. In this advert, what is meant by “get the upgrade that counts”? Respondents who saw the pictureQJ7. What is the main message of this advert? Respondents who saw the picture

Yes39%

No 51%

Refused/Do not know10%

Three-quarters of adults associate the women’s desire for their men to get circumcised with wanting to reduce the risk of contracting HIV

Seen the advert?

To reduce the risk of HIVTo reduce the risk of cervical cancer

To improve their sex lifeCircumcision is more hygienicRefused/Do not know

77

555048

2

%

Why do the women want their men to be circumcised?

N=37,664(n=3,617)OMO

N=14,572(n=1,494)MMP

QJ5. In the last 12 months have you seen this picture before?QJ8. Why do the women in the advert want their men to get circumcised? Respondents who saw the picture

The final say• There is a clear correlation between exposure to the Brothers for Life and

measurable positive attitudinal and behavioural outcomes-such as circumcision and condom use

• The results of this survey also indicate that a shift in behaviour is taking place among the youth of South Africa, including a move from traditional to medical circumcision.

• Brothers for Life is playing a significant role in influencing attitudes which in the long-term may impact the HIV epidemic in South Africa.

Acknowledgements• Funders: USAID/PEPFAR• Research team:

• Centre for Communication Impact: R Delate (formerly with CCI), L Mahlasela, B Goldblatt

• IPSOS: R Braz, S Fleetwood, A Squara• Data collection: IPSOS • Survey respondents