Helen Hajiyiannis, Alice Clarfelt, Tselisehang Motuba

1. Key findings from the post-broadcast reception analysis of We Beat TB television adverts 4 April 2012 Helen Hajiyiannis, Alice Clarfelt, Tselisehang Motuba Centre for AIDS Development, Research and Evaluation www.cadre.org.za

2. USAID TB Project • The USAID TB Project, coordinated through the University Research Corporation, is a 5-year programme (2009-2014) aimed at strengthening tuberculosis control & prevention initiatives in SA. • One of the key pillars of the USAID TB Project, the Advocacy, Communication and Social Mobilisation Strategy (ACSM), has been developed by Johns Hopkins Health and Education in South Africa (JHHESA). • Objectives of the ACSM strategy are to: (1) reduce number of new TB cases; (2) improve quality of TB services; (3) increase availability of TB treatment; (4) increase demand for TB services; (5) improve management of TB support systems.

3. USAID TB Project • Part of the ACSM strategy entails a mass media campaign called We Beat TB! • Three television personal service announcements (PSAs) were produced in several languages and broadcast on the national TV broadcaster. Radio PSAs were also produced. • The television PSAs were field tested prior to broadcast and findings were used to revise adverts and scripts.

4. USAID TB Project • The campaign has had four media bursts on national TV and radio stations: • November 2009 to January 2010 • March 2010 to April 2010 • October 2010 to December 2010 • July 2011 to September 2011 • A post-broadcast reception analysis was conducted in March 2012 focused on the television adverts. This was five months since adverts were last broadcast on TV.

5. Target audiences • Mass media component of strategy is implemented at national level, whereas community mobilisation activities are implemented at provincial and district levels. • Target audiences of TV adverts are urban, peri-urban and rural South Africans of all ages and particularly those between the ages of 16 to 64, from low to middle income households.

6. Description of three TV adverts and messages • Infection control: Open your windows and cover your cough. Messages: Open the window, cover your cough, and wash hands after coughing or sneezing to prevent the spread of TB. • Treatment adherence: Take 180 doses to be number one okay. Messages: Complete the full course of treatment to be cured of TB; “180 to be number one okay”.

7. Description of three TV adverts and messages cont. • TB/HIV co-infection: TB is curable even if you have HIV. Messages: TB is curable even if a person is living with HIV; get tested for HIV and TB.

8. Objectives of post-broadcast reception analysis cont. • Objective 1: Explore reception environment of the adverts. • Objective 2: Explore personal responses. • Objective 3: Explore contexts of interpersonal communication. • Objective 4: Explore relationship between educational objectives and actual reception • Objective 5: Identify gaps in TB knowledge & develop recommendations for development of new adverts.

9. Study design • Six focus groups were conducted with representatives of the target audience. • Focus groups were conducted in three South African provinces (Gauteng, Eastern Cape, KwaZulu Natal). • Focus groups were conducted to include three localities: urban, peri-urban and rural. • Focus groups included males and females and were representative of two age ranges: 18-30 years and 30 years plus.

10. Study design cont. • 39 people participated in the focus groups. 16 males and 23 females. • 28% of urban participants had tertiary education, 33% from peri-urban areas had matric or less and 80% of those from rural areas did not have matric. • Minimum criteria for inclusion: seen at least two TV adverts; willingness to talk openly. • Groups were conducted in language of participants’ choice, discussions audio recorded & audio files translated to English and transcribed verbatim.

11. Data analysis • Team of researchers involved in this project were tasked to each read through all of the transcripts and become familiar with the data. • A coding structure was developed that allowed for data from each advert to be coded separately, as well as for the coding of data that was general about the adverts. • Though an inductive approach was taken to the development of codes, care was taken to ensure that coding was done in relation to the key research questions.

13. Take 180 to be number 1 okay • Advert was well remembered and seen across the various localities. • Commonly was seen on SABC 1 or SABC 2 in English. Only participants from rural KZN had heard the advert on radio in Zulu. • Advert was generally described as “the advert with the dancing cartoons”, perceived as attractive, appealing and attention-grabbing. • Dancing was perceived as “local”, “South African” and appealed to youth culture.

14. Take 180 to be number 1 okay • Inclusion of dance was said to communicate a positive message about TB: • “I think the energy and the fact that the cartoons are dancing, it kind of clears the thought that if you have TB you are at death’s bed or something. So the fact that there is energy around it, it kind of improves the positivity” (Female, 18-30, urban, Eastern Cape).

15. Take 180 to be number 1 okay • There was some cross-over between adverts, with this advert including descriptions of when the animated characters go to the clinic to get tested (the HIV and TB co-infection advert). This can be attributed to having the ‘180’ visual message appear in both adverts.

16. Take 180 to be number 1 okay • Four aspects were identified and referred to as the distinguishing features of this advert: • (1) four dancing characters or cartoons; • (2) one of the animated characters begins to cough and changes colour; • (3) the animation showing pills being swallowed; and • (4) the inclusion of ‘180’ at a visual and audio level.

17. Take 180 to be number 1 okayUnaided recall: message takeout • Focus group participants reported four messages from this advert. Overall, the common message or lesson and the one most often reported as taken from this advert was the importance of completing the full course of TB treatment. • “What I saw as very important is that you must take your treatment in full because you default you will have a problem. You must persevere to the end” (Male, 18-30, peri-urban, KwaZulu Natal).

18. Take 180 to be number 1 okayUnaided recall: message takeout • The second most common message among focus group participants was that TB treatment needed to be taken for 180 days. • This message was often linked to the message about the importance of completing the full course of treatment: • “If you are a TB patient take your treatment for one hundred and eighty days” (Male, 30+, rural, KwaZulu Natal).

19. Take 180 to be number 1 okayUnaided recall: message takeout • Third message identified by participants emphasised the need for community and individual support in order to assist people to complete their TB treatment. • “There was an idea of community and not separating people with TB, because when the one character started breaking down, the others were like helping him or her up. There was an idea of community and not stigmatising TB, like separating TB people, but rather supporting them” (Female, 18-30, urban, Gauteng).

20. Take 180 to be number 1 okayUnaided recall: message takeout • Fourth message identified by participants, focused on debates around whether the ‘180’ referred to in the advert is referring to number of days of treatment or number of pills. • “Is it 180 days or 180 tablets, or is it the same?” (Female, 18-30, urban, Eastern Cape), while others, spoke about 180 doses of medication.

21. Take 180 to be number 1 okayUnaided recall: message takeout • There were clearly instances where participants had understood the message to be about the 180 pills: “It emphasises that a person has to take one hundred and eighty pills to cure TB” (Female, 18-30, peri-urban, KwaZulu Natal). • Another aspect identified as unclear, related to the visual representation of the animated character taking his pills, shown as a continuous flow of pills. This resulted in some thinking the advert was saying all 180 pills are taken at the same time.

22. Take 180 to be number 1 okayUnaided recall: message takeout • “M3: I have an issue with the animation. It’s like they take all their medication all at once. They should show properly how they take their medication. … • F4: I agree with M3. It’s like he is taking the whole medicine, so what does that say, that we must take the whole medicine?” (Male and female, 30+, peri-urban, Gauteng)

23. Take 180 to be number 1 okayUnaided recall: narration • Some participants in one of the groups commented on the narration of the advert, stating that there was a mismatch between the narrator’s voice and the actions of the cartoons. • The fact that the narrator’s voice begins about 15 seconds into the advert, seemed to make these participants only begin listening to the advert then.

24. Take 180 to be number 1 okayUnaided recall: narration • “M2: The narration is not relevant to the cartoons. You can hear there is someone speaking on the side and there are cartoons playing… There are two different things happening at the same time. This has made it to lose meaning. • M1: The picture depicted by the narration at the end does not relate with the actions that already took place. • F1: The narration is at the end. The cartoons are already played. By the time you listen the advert is over” (Male and female, 30+, rural, KwaZulu Natal).

25. Take 180 to be number 1 okayInterpersonal communication • There were examples of participants talking to others about the advert: (1) aspect that triggered discussion was the dancing cartoons; (2) a female participant described how she had discussed the advert with her roommates, discussing the topic of defaulting on treatment and the resultant consequences; (3) a male participant encouraged his wife, who had once had TB, to watch the advert on TB treatment; (4) a female participant talked with her children about the importance of treatment adherence.

26. Take 180 to be number 1 okayInfluence on behaviour • There were two instances reported by focus group participants of knowing someone who had been influenced to continue to take their TB treatment after watching the advert. Both were from rural localities. • “My relative was on treatment and wanted to default thinking he was cured. By watching this advert he was encouraged to take the pills for 180 days because he does not want the disease to come back” (Male, 30+, rural, KwaZulu Natal).

27. Take 180 to be number 1 okayInfluence on behaviour “F2: I have a friend of mine who was helped by this advert. She stopped taking her pills and drank (liquor). She thought she was alright, about three months she was healthy, but after then she fell sick again. She had to start all over again to take the treatment. Facilitator: She had stopped taking treatment… F2: She had stopped yes. She thought she was healed. When watching the advert, she saw the character cough and collapse, we joked about it and said she will be like that” (Female, 30+, rural, KwaZulu Natal).

28. Take 180 to be number 1 okayAided recall: message take-out • Participants identified the same messages as during unaided recall. The debates around ‘180’ continued and within the context of aided recall, participants noted that even though they had paid close attention to this aspect of the advert, it was still not clear to them what was meant by 180 doses: is it 180 doses of pills i.e., pills taken once a day, or does it mean that pills are taken over a period of 180 days, but that there can be more than one daily dose and or, more than one pill.

29. Take 180 to be number 1 okayAided recall: message take-out • Commonly, among participants that were unclear what ‘180’ referred to, there were also remarks about the advert being “too busy” and that the narration around ‘180’ took place as the same time as when music played, contributing to a lack of clarity. • “I think the part that says you have to take 180 days of medicine, 180 days, so we thought it was 180 tablets” (Female, 18-30, urban, Eastern Cape).

30. Take 180 to be number 1 okayAided recall: message take-out • Three participants identified the message after watching the advert, as being that TB treatment takes 52 days to complete. • This may have been as a result of seeing this figure during aided recall, whereas previously had not noticed them, or had understood that when the numbers are flashing by and stop briefly at ‘52’, that this meant the end of treatment. • Unclear if this is as a result of aided recall context and focusing closely on the advert, or due to the existence of the potential for misunderstanding the message.

31. Take 180 to be number 1 okayAided recall: recommendations • Reduce number of messages and make advert less busy. • Voiceover or narration be clear and match the actions in the advert. • Drop references to 180 doses of medication, rather focus on a sentence that says something like, “you should take your tablets within 180 days” (Female, 18-30, urban, Eastern Cape).

32. Take 180 to be number 1 okayAided recall: recommendations • Have calendar appear close to person taking the pills rather than elsewhere in the frame, so when watching person taking pills, the calendar is linked to this person. • Have narrator clearly articulate the consequences of defaulting on treatment, noting aspects such as person will get sick again (or importantly, infect others), may develop treatment resistance. • Common question was whether antiretrovirals (ARVs) can be taken at the same time as TB medication.

34. TB/HIV co-infection: Overall views • This advert generated a strong response, and critical engagement with and debate over features of the animation. • Multiple messages were derived, including: • How TB impacts the immune system destroying your “balance”. • Everyone is vulnerable to TB infection. • You can be cured of TB if you are HIV positive.

35. TB/HIV co-infection: Overall views cont. • Overall participants liked the ad and found positive meaning in it. • Some participants struggled to remember the advert during unaided recall. • After aided recall additional meanings were found. • The target audience was said to be younger people living in more urban areas, as older rural people would not understand the animation.

36. Unaided recall: Message takeout • Everyone is vulnerable to TB infection: One must test for TB. • TB does not discriminate according to HIV status. • One must maintain a hygienic lifestyle, washing hands and eating healthy food. • Your treatment is the same if HIV positive or negative (need for clarification).

37. Unaided recall: Message take-out • Positive knowledge acquisition – TB can be cured even if you are HIV positive: • Inspires hope • Helps de-stigmatize TB • One must take one’s family to the clinic, knowing they can be cured • Symbolism around the pots and pans on people’s heads: • The “story of the kettle and the pot” (idiom) – do not judge someone else when you are in the same situation • TB can make you lose your “balance” or “power” – you need to take TB treatment to regain your balance. • The pots were also described as “symbols of the future” – which you can rebuild “the tin falls, but you can still lift your tin” (female, 18-30, peri-urban, KZN)

38. Unaided recall: Message take-out • Positive knowledge acquisition – TB can be cured even if you are HIV positive: • Inspires hope. • Helps de-stigmatize TB. • One must take one’s family to the clinic, knowing they can be cured.

39. Unaided recall: Message take-out • Symbolism around the pots and pans on people’s heads: • “Story of the kettle and the pot” (idiom) – do not judge someone else when you are in the same situation. • TB can make you lose your “balance” or “power” – you need to take TB treatment to regain your balance. • The pots were also described as “symbols of the future” – which you can rebuild “the tin falls, but you can still lift your tin” (female, 18-30, peri-urban, KZN).

40. Clarity – UR messaging • Confusion / ambiguity over “180” – number of days or pills? Still unclear after aided recall. • Ambiguity over whether can take TB treatment whilst taking ART (gaps in information). • Some participants did not understand the significance of the pots and pans. • In one group participants thought the narration needed to be stronger / more present.

41. Influence on behaviour and interpersonal communication • There were no explicit examples of participants taking a particular action in relation to this advert. New information acted as a catalyst for generating conceptualised forms of action (going to the clinic, getting tested etc). • There were no clear examples of interpersonal communication. In one focus group (18-30, urban, Eastern Cape) participants said that TB is not something that is talked about openly. Would mention ads in passing, not in depth discussions.

42. Unaided recommendations • Several participants said they would like clearer narration for clarification on how to take your medication, and what the characters learnt from going to the clinic. • Narration was preferred to writing (some are illiterate). • Some participants wanted more from the visual quality of the animation – more colour, more vivid – the setting was said not to be clear.

43. Aided recall: Message take-out • After seeing the advert, discussants identified certain features more clearly which led to enhanced interpretations of messaging • Participants liked how the HIV negative person became ill first, showing that we are all susceptible to HIV. • The laughter was more clearly identified, and how this follows on from the coughing. A common interpretation was that one character thinks he is better than the other one “the saying of the kettle and the pot” – but we are all vulnerable to HIV infection, and whether we are HIV positive or negative.

44. The story of the pot and the kettle • “In as much as the other one is thinking that he is better than the other one, they’re in the same situation. Even the made the cartoon’s head the pot and then the other one the kettle, put more emphasis on it, because if she hadn’t said it, even now looking at it again, I wouldn’t have noticed. But it does have a lot significance”.

45. The story of the pot and the kettle cont. • “The pot and the kettle are in the same pot, as in they both go to the same fire, but most of the time you find the pot. So when they go to the same fire, they are HIV negative and positive, so the TB is maybe saying you are in the same pot. So they are saying the Xhosas and the Zulus understand the pot and the kettle thing, but other cultures wouldn’t understand it” (Female, 18-30, urban, Eastern Cape).

46. AR: Message take-out • Advert was said to counteract stigma by showing that TB affects HIV+ and HIV- people and that one can be cured if you are HIV positive. • After aided recall participants commented more extensively on features eg., the pots: • More noticed characters getting tested. • There was more clarity around treatment taking time-period, and for HIV+ and HIV-. • Pots symbolise that we are all the same / balance the same things in life. • Pots are our every day responsibilities.

47. Pots represent our everyday world • It represents your everyday things, your routine that you do, I could say it represents your world, and that when you are weak, your world falls apart, because it’s your basic needs, your kettle and whatnot. So those are things that were up straight when you were healthy, you were able to carry them on, but when you are weak, they start falling apart because you cannot do certain things (Male, 18-30, urban, Gauteng).

48. AR – Unintended Messaging • Increased attention to how one character laughs at another – interpretation that he is laughing because the other one is sick. • One participant (female, rural, Eastern Cape, 30+) thought that TB was transmitted through germs on the pots and pans to the other character. • Some confusion over the bird and the dog. One participant attributed TB infection to the dog. (Male, peri-urban, 30+, Gauteng).

49. Aided recall - Recommendations • Desire to see different social classes in the ad, and within different settings. • Gap in information identified – if you are positive do you take same treatment as someone who is negative? Need for clarity. • Gap in information: Does it take longer for an HIV positive person to be cured than an HIV negative person? • Desire for clearer narration, either written or spoken.

50. Aided recall - Recommendations • There should be the same level as attention on TB as on HIV in media campaigns. TB is a serious threat. • Ad could have reached a broader audience by including more modern items like laptops, rather than just pots and pans – implication that this is not just targeted at people from a poorer socio-economic background.