1. The Impact of Brothers for Life on the uptake of Medical Male Circumcision Lusanda N Mahlasela Centre for Communication Impact

2. Contents 1 background and objectives 2 key limitations main findings 3 4 the final say

3. 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

4. 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

5. 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 17 th September to 19 th of October 2015 Ethics approval was granted by the Human Sciences Research Council Ethics Committee Methodology

6. 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

7. 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)

8. 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)

9. Main findings

11. 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?

12. Medical Male Circumcision campaign

13. Males: Are you circumcised? N=18,139 (n=1,801) OMO Females : Is your partner circumcised? N=19,525 (n=1,816) OMO QI19.1. Are you circumcised? Male respondents QI19.2. Do you know if your partner is circumcised? Female respondents Circumcision increases with exposure to the Brothers for Life campaign

14. B4L ExposureCircumcision Date NoneSomeMediumHighLast 3 years˃3 yrs n=5243783971210167760 N=6,1174,0064,02111,7201,6467,506 66%74%76% 77%79% 75% 67% 68% 76% 72%74% 50%60%58%62%59%60% 21%36%25%31%33% 20%27%21%28%33% 12%6%4%2% 4% 2%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 N=25,864 (n=2,509) MMP QI17. Why do you think men should get circumcised? Respondents who think men should get circumcised

15. There has been a generational shift from traditional to medical circumcisions, as is evident from the age profiles of circumcised men. TotalGPWCKZNMPFSNWLPECNC n=1,01634398150835522*10613722* N=10,0792,5299221,6441,0486083551,3691,352250 Medical51%59%48%72%51%59%62%39%9%97% Traditional45%34%45%24%46%41%38%59%87%3% Traditional 45% Medical 51% Total 15-17 years 18-24 years 25-34 years 35-49 years 50+ n=1,01628*243336279127 N=10,0792672,6502,6472,5731,923 Medical51%96%63%56%42%33% Traditional45%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

16. …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 testYes: 50%No:46% Condom First Sex Yes: 53%No: 42% Condom Last Sex Yes: 59%No: 36% HIV testYes: 35%No:62% Condom First Sex Yes: 29%No: 66% Condom Last Sex Yes: 35%No: 59% QI19.1. Are you circumcised? Male respondents

17. 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? 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 picture QJ7. What is the main message of this advert? Respondents who saw the picture

18. 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? 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

19. 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.

20. 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