Using entertainment-education to promote safer sexual behavior in young adults in Nigeria

Background: Systematic reviews show that HIV prevention campaigns are often ineffective in reducing risky sexual behaviors. Promoting safer sexual practices among high-risk individuals is key in curbing the HIV epidemic. Entertainment-education is the use of mass media programming with educational and development objectives. MTV Shuga is an educational television series aimed at promoting safer sexual practices among Africa youth. Using data from a randomized control trial in Nigeria, this thesis studies the effectiveness of MTV Shuga on promoting safer sexual practices among the high-risk youth from the general urban population; and investigates the mediating effects of psychosocial and immersion mediators on the program’s impacts on increased HIV testing.
Methods: This thesis is comprised of three studies. The first is a meta-analysis of entertainment-education narratives conducted in field settings in developed and developing countries (n=10 studies; 23,476 individuals). Effect sizes were meta-analyzed using random-effects models. The moderators paper is the second study of this thesis. This paper studied the average treatment effects of MTV Shuga on high-risk youth (n=2,073), including average treatment effects by gender (sub-group analysis); and the moderating effects of religion and television-watching habits for this high-risk population (effect-modification analysis). Data was analyzed from 18-25-year-olds from the urban general population that at baseline reported at least one of the following HIV-risk factors: had unprotected sex in their last sexual encounter, engaged in sexual concurrency, had a sexual partner older/younger by ten years, or reported having symptoms of a STI. The moderators analysis is based on intent-to-treat estimates.
The mediation analysis is the third paper of this thesis. It aimed to identify the mechanisms through which MTV Shuga impacted one of the program’s objectives, the uptake of HIV testing. The study sample is restricted to individuals that were sexually active at baseline and for whom the Shuga trial had data for HIV testing and all tested mediators at follow-up (n=1,894). The analysis is based on the mediation approaches of Hicks and Tingly (2011) and Preacher and Hayes (2008). Given methodological limitations and the post-hoc nature of the analysis, the results of the thesis should be read as hypothesis-generating evidence.
Results: In the first study, the meta-analysis found suggestive evidence that entertainment-education narratives had small but statistically significant effects for three out of four high-risk sexual behaviors. This communication approach reduced the number of sexual partners, reduced unprotected sex rates, and increased testing and management for STIs. However, entertainment-education was not effective in reducing inter-generational sex. It had medium-size effects on knowledge outcomes, where a time-decay relationship is observed. This study found no effects on HIV attitudes.
The second study provides suggestive evidence that MTV Shuga increased HIV testing among high-risk individuals, and decreased the average number of current sexual partners. It increased knowledge about HIV transmission and reduced stigma and negative attitudes towards HIV-positive people. However, this paper did not find effects on chlamydia infections, condom use, and inter-generational sex. This study provides indicative evidence of consistency of program effects across different populations: Program effects for high-risk youth were similar to results reported for the average study participant. Program effectiveness among high-risk youth did not differ by participant’s religion or television-watching habits.
In the third study, the mediation analysis found that impacts on a self-reported HIV testing measure (eight-month follow-up survey) were mediated by knowledge about HIV transmission, attitudes towards HIV+ people and program transportation. The latter had the strongest influence, mediating a quarter of the total effect. For an objective HIV testing measure collected two months after the follow-up survey, program transportation remained the most influential variable though it was no longer statistically significant.
Conclusion: This thesis shows that mass media entertainment may be an effective tool in promoting safer sexual practices among youth. Although it generally found small behavioral effects, the economies of scales of entertainment-education over face-to-face interventions suggest its potential to be a cost-effective tool above an audience threshold. The thesis provide indicative evidence about the “transportability” of entertainment-education narratives. Partly mediated by program transportation, MTV Shuga’s effectiveness on psychosocial and behavioral outcomes was similar for different youth populations in Nigeria. Given the limited effectiveness of traditional HIV prevention campaigns, research is needed to understand how best these campaigns could be complemented with entertainment-education modules.

Keywords: sexual behaviors
randomized control trial
impact evaluation
adolescents and youth
mass media
HIV prevention intervention
meta-analysis
Advisor: Cluver, L