Stigma Reduction through Entertainment Education: The effectiveness of MTV Shuga on reducing HIV/AIDS-related stigma among university students, high school students and school dropouts in Cape Town, South Africa

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Stigma Reduction through Entertainment Education: The

effectiveness of MTV Shuga on reducing HIV/AIDS-related stigma

among university students, high school students and school dropouts

in Cape Town, South Africa

Name: Anne Loes Kreijtz

First supervisor: Dr. J.S. Brommundt Second supervisor: Dr. L. Löfquist Date: 17-07-2018

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This thesis is submitted for obtaining the Joint Master’s Degree in International Humanitarian Action. By submitting the thesis, the author certifies that the text is

from his own hand, does not include the work of someone else unless clearly indicated, and that the thesis has been produced in accordance with proper academic

practices.

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Acknowledgements

I would first like to thank the first supervisor of my thesis, Dr. Jan Brommundt, for providing supervision, advice, support, motivation and feedback throughout the whole process of my thesis.

Secondly, I would like to express my gratitude to the HIV and AIDS Programme of the University of the Western Cape, for making this thesis possible. Without the support of everyone involved within the HIV and AIDS Programme, I would never have been able to conduct this study. During my time at the HIV and AIDS Programme, I have acquired extensive knowledge on a broad range of issues concerned with the topic of HIV/AIDS, both related and not related to my own study. Furthermore, it was a blessing to work with such inspiring and dedicated people and I would like to thank the whole team for giving me such a warm welcome to the team and to South Africa. Special acknowledgements are addressed to Mr. Joachim Jacobs and Dr. James Lees, for their support and feedback on my topic, the data-collecting process and for always providing me with food for thought. I would like to thank Tammy Prince and Lungisile Kweyama for their support with the data-collection sessions, but foremost, I would like to thank them for always brighten up my days and inspiring me to work hard to achieve my goals. I would also like to thank Meryl Adams, for the practical support she provided for the data-collecting sessions and the peer-educators of the HIV and AIDS Programme for providing a helping hand during the sessions.

Lastly, I would like to address my acknowledgements to Mwila Mulubwa, for guiding me in the world of SPSS, to Kalpita Patel, for her thoughts on my research design and her support during the first data-collection session, and to Dr. Lars Löfquist, for reviewing the final version of my thesis.

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List of abbreviations

AIDS Acquired Immune Deficiency Syndrome ART Antiretroviral Therapy

EE Entertainment Education

E-ELM Extended Elaboration Likelihood Model

FGD Focus Group Discussion HIV Human Immunodeficiency Virus

HIV+ HIV positive

LGBT Lesbian, Gay, Bisexual and Transgender MTV Music Television

NOHA Network on Humanitarian Action PLWHA People Living with HIV/AIDS SANAC South African National Aids Council SCT Social Cognitive Theory

SPSS Statistical Package for the Social Sciences STD Sexually Transmitted Disease

TB Tuberculosis

UNAIDS United Nations Programme on HIV/AIDS

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Introduction

Although the global HIV/AIDS epidemic seems to be stabilizing, Southern Africa remains the most affected region in the world (Mbonu et al., 2009). In 2015 the region was home to almost 25,5 million people living with HIV/AIDS, which led to around 800.000 AIDS-related deaths in the same year (UNAIDS, 2016). In addition to the physical burden of living with HIV/AIDS, the illness also carries a psychological burden. Despite the fact that the disease is widespread, people living with HIV/AIDS (PLWHA) still experience discrimination and stigmatisation. This HIV/AIDS-related stigma negatively affects the treatment of PLWHA by communities, families and partners, which can lead to isolation from the community and decreases their overall quality of life (Mbonu et al., 2009, pp. 1). The existing stigma also poses challenges to the public health situation, as it negatively affects preventive behaviours such as condom use, HIV test-seeking behaviour, care seeking behaviour after diagnose and the quality of care provided to PLWHA (Brown et al., 2003, pp. 49). For these reasons, the reduction of the HIV/AIDS-related stigma is a vital step in the fight against the HIV/AIDS epidemic in Sub-Saharan Africa.

The recognition of the crucial role of reduction of HIV/AIDS-related stigma in the fight against HIV/AIDS has been increased during the last twenty years. In 2000 the International AIDS Conference was held in Durban under the revealing title ‘Breaking the silence’ and stigma and discrimination were still key topics at the International AIDS Conference of 2018. The recognition of the importance of reducing the current stigma has also led to new stigma-reduction strategies and many stigma-reducing interventions (Heijnders et al., 2007, pp. 354). The negative social and public health challenges as described above, make it necessary for HIV/AIDS-programmes to not only focus on prevention and treatment HIV/AIDS-programmes, but on programmes aiming to reduce HIV/AIDS-related stigma as well. As stigma limits PLWHA in preventive behaviour and care seeking behaviour, treatment and prevention programmes will not be fully effective when HIV/AIDS-related stigma still exists. Therefore, strategies and interventions aimed to reduce HIV/AIDS-related stigma are essential in the fight against the epidemic.

There are three existing studies that review intervention studies on stigma-reducing interventions. The first study is the study by Brown et al. published in 2003. This study aims to describe interventions aimed at decreasing AIDS stigma,

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summarize common characteristics and audiences, and identify which aspects of these interventions have proven to be successful (Brown et al., 2003, pp. 50). The study reviews 22 different studies on HIV/AIDS-related interventions with at least one reducing element. The second review on intervention studies on stigma-reducing interventions is the study by Heijnders & Van der Meij, published in 2006. This study aims to identify stigma-reducing strategies and interventions in the field of HIV/AIDS, mental illness, leprosy, TB and epilepsy (Heijnders & Van der Meij, 2006, pp. 353). The main difference between this study and the study by Brown et al. is that this study focuses on stigma reducing-interventions related to different medical conditions, while the study of Brown et al. focuses on HIV/AIDS-related stigma-reducing interventions specifically. The third existing review study is the study by Sengupta et al. published in 2011. This study builds on to the study by Brown et al. by determining the effectiveness of interventions aimed at reducing HIV/AIDS-related stigma, with the main difference that this study takes the quality of the interventions reviewed into account as well.

These three studies all identify one research gap. Despite the increased recognition of essential role of stigma reduction in the fight against HIV/AIDS, and the increased number of new stigma-reducing strategies and interventions, limited academic research has been conducted on the effectiveness of these interventions. A vast majority of existing studies on the effectiveness of HIV/AIDS-related interventions are on interventions promoting prevention measures, mainly sexual education programmes, while there is a limited number of studies examining interventions aimed at reducing HIV/AIDS-related stigma (Sengupta et al., 2011, pp. 1076). Heijnders & Van der Meij identify the same research gap by stating that although a lot of work has been carried out on stigma and stigma reduction strategies, far less work has been done on the effectiveness of these stigma reducing strategies (2007, pp. 253). Brown et al. describe the same gap as they state that there are relatively few interventions aimed at reducing HIV/AIDS-related stigma rigorously evaluated, documented and published. According to them, future research is to benefit and learn from past interventions and therefore results of these interventions need to be widely disseminated (2003, pp. 66).

This study aims to contribute in overcoming this research gap by examining the effectiveness of one specific intervention in reducing HIV/AIDS-related stigma: MTV Shuga season 4. MTV Shuga is a television series developed to improve sexual

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and reproductive health among young people, by addressing several social issues such as safe sex, HIV-testing, HIV-stigma, teenage pregnancies, sexual violence, LGBT-stigma, economic empowerment and the importance of education. This study aims to examine the effectiveness of MTV Shuga on reducing HIV/AIDS-related stigma among university students, high school students and school dropouts in Cape Town, South Africa. The study is conducted according to the following research question: ‘What is the effect of MTV Shuga’s season 4 on HIV/AIDS-related among university students, high school students and school dropouts in Cape Town, South Africa?’. The reason why season 4 is chosen for this study, instead of the other seasons of the series, can be found in the storyline of the season. Season 4 specifically focuses on a broad range of topics surrounding HIV/AIDS-related stigma.

To answer the research question, the context and roots of HIV/AIDS-related stigma first need to be understood. Therefore, a deeper understanding of the origins of stigma and HIV/AIDS-related stigma, HIV/AIDS-related stigma in South Africa, and the role of different interventions strategies, will be given in the first chapter. The methodology of the study will be described in the second chapter, followed by a presentation of the results in the third chapter. In chapter four, the implications of the results, the research limitations and the recommendations for future studies will be discussed. Last, the conclusions of the study will be presented.

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1. Background information

1.1. Stigma and different types of stigma

One of the first scientists providing a theorization of stigma that is now generally recognized was the sociologist Ervin Goffman. He described stigma as ‘an attribute that is deeply discrediting’. (1963, pp.3). Following Goffman, Alonzo and Reynolds provided a more extensive theorization of stigma while stating that stigma is ‘a powerful discrediting and tainting social label that radically changes the way individuals view themselves and are viewed as persons’ (1995, pp. 304). This statement by Alonzo and Reynolds indicates that a distinction can be made between different types of stigma, as he describes that individuals can view themselves in a certain way, however people are also viewed by others in a certain way. Kleinman refers to these different types of stigma and adds a third type of stigma by stating that ‘the stigmatization process usually begins with the community’s response to the person, but eventually the person comes to expect such reactions. The person starts to anticipate them before they occur and even when they do not occur.’ (1988, pp. 159). This statement indicates four different kinds of stigma and also shows that these types of stigma intertwine. The four levels of stigma that can be distinguished are: public

stigma, internalized stigma, experienced stigma, and anticipated stigma. Public

stigma can be defined as the stereotypes held by the general public about the other, which is in this case the community’s stereotypes about PLWHA (Pattyn et al., 2014, pp. 232). Internalized stigma can be described as the way people feel about themselves. This can include feelings of shame and fear. These feelings of shame and fear often relate to experienced stigma. Experienced stigma can be defined as the actual experience or occurrence of prejudice, discrimination and stereotyping towards others (Fay et al., 2011, pp. 1089). As Kleinman already described, after experienced stigma, people eventually become to expect such reactions (1988, pp. 159). This process can be defined as anticipated stigma. Anticipated stigma is the belief that prejudice, discrimination and stereotyping will be directed at the self from others in the future (Earnshaw & Chaudoir, 2009, pp. 1161).

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1.2. Factors mediating HIV/AIDS-related stigma in Sub-Sahara Africa

According to Mbonu et al, HIV/AIDS has been accompanied by stigmatisation everywhere in the world, but stigmatisation in Sub-Saharan Africa seems to be particularly common (2009, pp. 3). They define four factors that seem to mediate HIV/AIDS-related stigma; Cultural constructions of HIV, stereotypes and specific beliefs, access to and the role of antiretroviral therapy (ART), religion and gender (Mbonu et al., 2009, pp. 3).

Regarding cultural constructions, stereotypes and specific beliefs, Malcom et al. state that fears associated with illness, disease and sex need to be viewed in a broader social and cultural context, as each society has their own meaning and explanations for sickness, ideas about disease transmission and sexual behaviour (1998, pp. 351). Fears may be about transmission through every day contact. However, they may also arise from pre-existing attitudes and believes. According to Malcom et al., it are primarily these kinds of responses that may result in stigmatisation and discrimination (1998, pp. 352). Kleinmann stresses that social markings of a disease stigmatise, because they break cultural conventions about what is acceptable appearance and behaviour, while invoking other cultural categories of what is ugly, feared, alien or inhuman (1988, pp. 159). In many Sub-Saharan societies, social markers developed to identify those who have been infected. Such markers help define the social group by projecting its negative values on the other who will become marked as defective or depraved. These social markers may include physical symptoms. Physical manifestations of advanced disease are often considered as clear indications of immoral behaviour and can mark someone to be avoided or as a threat (Duffy, 2005, pp. 15). A study of Duffy in Zimbabwe showed that most participants were of opinion that they could recognize someone who had HIV or AIDS, without differentiation between the stages of the disease (2005, pp. 15).

Social markers are not the only cultural construction, stereotype or specific belief leading to stigmatisation. HIV/AIDS being viewed as a ‘polluted disease’ is a reoccurring phenomenon in Sub-Saharan Africa. This reflects the negative attitude towards the way HIV enters the body. As HIV is a sexually transmitted disease (STD) and the risk of contracting HIV increases significantly with the presence of other STD’s, the view of HIV as a polluted disease seems to origin from negative attitudes towards sexual behaviour and STD’s in general. In many African societies, HIV is

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seen as a punishment for immoral sexual behaviour (Malcolm et al., 2007, pp. 351). Furthermore, HIV/AIDS is stigmatising because it carries many symbolic associations with danger. Attributions of contagion, incurability, immortality and punishment for sinful acts are common in many African societies (Mbonu et al., 2009, pp. 3). HIV is culturally constructed as a disease accompanied by the threat of death and disfigurement, which adds to the fears and fantasies surrounding the disease. According to Malcolm et al., this resulted in characterisations of HIV as a disfiguring and frightening disease, with little hope for recovery or cure and which threatens to devastate communities and societies (2007, pp. 350).

Access to ART can both increase and decrease HIV/AIDS-related stigma. On the one hand, when receiving ART, the people around the infected person generally become more aware of their HIV status. This can increase the personal impact of already existing stigmatisation (Mbonu et al., 2009, pp. 5). On the other hand, ART prolongs the asymptotic phase of HIV significantly. The effect of a prolonged asymptotic phase due to ART on reducing HIV/AIDS-related stigma is intertwined with physical symptoms functioning as social markers. When the physical symptoms are not there or not visible because of ART, these physical symptoms cannot function as social markers. This can make the PLWHA less vulnerable to stigmatisation. Furthermore, the prolonged asymptotic phase makes that PLWHA are less influenced by the disease in their daily lives. As symptoms of the disease stay out, PLWHA will still able to function optimally in their day-to-day lives and to provide for their families. This limits potential separation, status loss and labelling (Mahajan et al., 2008, pp. 70). Another effect of ART is that, when the virus is detected in an early stage, PLWHA can have the same life expectancy as people who are not infected with the virus (UNAIDS, 2014). Therefore, being infected with HIV does not mean a certain death anymore. This can decrease the cultural construction of HIV as a disease accompanied by the threat of death.

Religion can also play a role in both increasing and decreasing HIV/AIDS-related stigmatisation. Just like cultural believes, religious beliefs can lead to stigmatisation. According to Gilmore & Somerville, religions use concepts with stigmatising potential such as sin, quilt, and evil to promote acceptance of certain moral positions (1994, pp. 1342). Some of these concepts have been applied to HIV or PLWHA. PLWHA are often considered as sinful or evil, leading to increased HIV/AIDS-related stigma (Kleinman, 1988, pp. 159). In many Sub-Saharan African

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countries, religion has an important role within society. This means that religious leaders have the possibility to be tempted to exercise power over others. Religious leaders can therefore influence their adherents by stigmatising PLWHA as sinners or impure. This strengthens broader social stratifications in which stigma flourishes. On the contrary, when PLWHA remain included in the religious community, the separation between ‘us’ and ‘them’ disappears, which can decrease stigmatisation (Mbonu et al., 2009, pp. 5).

The last factor contributing to HIV/AIDS-related stigma in Sub-Saharan Africa can be found in gender. Parker & Aggleton state that pre-existing inequalities in societies work as a mediator for HIV/AIDS-related stigma (2003, pp. 14). These pre-existing inequalities are the foundation of HIV/AIDS-related stigmatisation towards women in Sub-Saharan Africa, as many African societies depend on pre-existing unequal economic and social constructions. Women are often economically and socially disadvantaged and to large extend outside of power structures and decision-making processes (Malcolm et al., pp. 357). According to Gilmore & Somerville, these power relations are central to stigmatisation, as stigmatisation is an exercise of power over others and a manifestation of disrespect for them (1994, pp. 1342). In a number of African societies, unequal power relations, like control over women’s movement, voice and opportunities, are among other things based on the belief that women will become promiscuous if grated too much freedom (Mbonu, 2009, pp. 10). This leads to the belief that women can be seen as the major transmitters of HIV and other STD’s (Malcolm et al., pp. 357). In the context of these unequal relations, men’s promiscuity is more easily accepted or at least tolerated. Women on the other hand, are expected to remain faithful to their husbands. For this reason, it appears that stigma associated with HIV is more serious for women who already experience unequal power relations, as women will often be blamed when they are recognized as HIV-positive (Duffy, 2005, pp. 16).

1.3. HIV/AIDS-related stigma and public health outcomes

As stated in the introduction, HIV/AIDS-related stigma not only negatively affects the treatment of PLWHA by their communities, families and the general population, stigma can also influence public health outcomes. Stigma related to HIV/AIDS is closely related to delays in help seeking, diagnostic testing and treatment seeking.

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Furthermore, stigma and discrimination can lead decrease the quality of care provided to PLWHA, influence preventive behaviour and affect health insurance coverage for PLWHA.

The first public health aspect influenced by HIV/AIDS-related stigma is diagnostic testing. Kalichman and Simbayi state that stigmatizing beliefs about HIV/AIDS and associated fears of discrimination, and thus anticipated stigma, often influence decisions to seek HIV-testing (2004, pp. 573). This statement is support by a study of Haffejee et al. among university students in South Africa. This study shows that university students who have low stigma levels, are significantly more likely to get tested at the university health facility (2018, pp 1). Furthermore, the results also show that individual preferences for an HIV-testing location are likely influenced by the relative amount of perceived stigma in that location (Haffejee et al., 2018, pp. 7). The influence of HIV/AIDS-related stigma on test seeking behavior is also shown by a study of Sambisa et al. They found evidence in a Zimbabwean national population-based survey that the fear of social rejection was inversely associated with uptake of voluntary testing, testing when offered and testing when required among Zimbabwean women (2010, pp. 170). Moreover, the results of this survey showed that respondents, who knew someone with HIV or had observed discrimination against someone with HIV, were more likely to get tested themselves (Sambisa et al., 2010, pp. 170). These two studies show the influence of anticipated and experienced stigma on test-seeking behavior for HIV-infection. However, public stigma can influence test-seeking behavior as well. This is shown by a study of Muyinda et al., as they state that the specific belief that HIV is incurable prevents people from getting tested (1997, pp. 144). As people fear HIV is incurable and will mean a certain death, they also believe knowing your status will not make a difference. The results of these three studies indicate that persons with lower levels of stigma, are more likely to get tested and therefore that higher levels of HIV/AIDS-related stigma can lead to delays in test-seeking.

HIV/AIDS-related stigma not only negatively affects test-seeking behavior for HIV-infection, it can also negatively affect test-seeking behavior for other STD’s. A study by Moss in Kenya showed that stigma associated with HIV enhances the stigma towards STD’s. Respondents of this study believed that persons with STD’s were seen as HIV-positive as well by the general population. This fear caused a delay in test-seeking for STD’s. The study also found that the greater fear of HIV minimizes

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the perception of the seriousness of STD’s, which can also lead to delays in STD testing. (Moss, 1999, pp. 104).

As seen from the previous paragraphs, HIV/AIDS-related stigma both influences test-seeking behavior for HIV infection and for STD’s. However, fears, specific beliefs and stigmatization can also lead to delays in seeking treatment and medical assistance. According Muyinda et al., HIV/AIDS-related stigma can cause people to stay away from health facilities, but also makes people turn to traditional healers instead of modern medicine. They describe that the fear of seeking medical assistance, can be caused by the fear that HIV is caught in modern hospitals, ‘where so many people go to die’ (Muyinda et al., 1997, pp. 144). In their study conducted in Uganda, they found that some people feel discomfort with the process of receiving treatment in modern health centers, as they dislike waiting to see a doctor and often feel like other patients are judging them in the waiting room or the pharmacy. Kalichman and Simbayi also found these tendencies. They specify that the primary reason not to get tested among HIV-positive women in Sub-Saharan Africa, is the fear of stigma (2004, pp. 573). Due to this fear of stigma, some participants of the study by Muyinda et al. turned to traditional healers instead of modern health clinics, as traditional healers can visit at home, at night and always have herbal treatment available. By doing so, people feel like there treatment is more anonymous, as they do not have to wait for a doctor, or stand in line to receive medication. This turn to traditional healers is also intertwined with the belief that HIV, or the symptoms of an HIV infection, are caused by external forces, such as witchcraft (Muyinda et al., 1997, pp. 144). Besides the influence of HIV/AIDS-related stigma on seeking HIV-treatment, this stigma can also influence treatment seeking for other medical conditions. This is especially the case for opportunistic infections, like TB (Macintyre et al., 2001, pp. 161). As opportunistic infections like TB are being associated with HIV, a fear exists that one will be labeled as HIV-positive by their community or family when being treated for an opportunistic infection.

The third public health aspect affected by HIV/AIDS-related stigma can be found in preventive behavior. According to a study by Macintyre et al., HIV/AIDS-related stigma can influence condom use. They identified a fear that insisting to use condoms may lead to the assumption that someone is HIV-positive (Macintyre et al., 2001, pp. 161). This fear may results in hesitation of condom use. Besides the influence of HIV/AIDS-related stigma on condom use, Macintyre et al., also describe

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the failure to refer sexual partners for testing and the fear to disclose status (Macintyre et al., 2001, pp. 161). As anticipated stigma can lead to anxiety to disclose ones HIV status, it can also lead to hesitation, refusal or delay in warning sexual partners after being diagnosed with HIV or after being at risk of becoming infected with HIV. Both of these factors can be a direct threat to the public health situation, as both of these factors can directly lead to new HIV-infections and thus contribute to a further spread of the epidemic.

Besides the effect of stigma on the behavior of people who might have been in risk of being infected with HIV or who are HIV-positive, HIV/AIDS-related stigma can also influence the quality of care provided by medical professionals in health clinics or hospitals. In their research to the forms and contexts of HIV/AIDS-related stigmatization and discrimination, Malcolm et al. reported refusal of providing treatment to PLWHA by medical professionals, judgmental attitudes of hospital personnel towards PLWHA or people who had been in risk of an HIV-infection, PLWHA being left alone in hospital beds without attendance by hospital staff and denial of hospice facilities and medication to PLWHA (2007, pp. 360-361). A study of Uwakwe et al. in Nigeria also proves the existence of stigmatizing attitudes and fears among medical personal, in this case among registered nurses. They found that 86,5% of the respondents of their study feared that there was at least some chance of contracting HIV when treating HIV-positive patients (Uwakwe et al., 2000, 421). 40% of the respondents disagreed with the statement that PLWHA should be treated no differently from others in the hospital and 50% of the participating nurses stated that they would not work with PLWHA if given the choice (Uwakwe et al., 2000, 422).

In the context of the influence of HIV/AIDS-related stigma on the health care system, confidentiality can be identified as a major issue as well. Malcolm et al. report that information about one’s HIV status is not always well protected. In some situations, medical staff has been informing those who they believe need to know, this can include family members and relatives, regardless of the consent of the patient concerned (2007, pp. 361). This can engender further discrimination and can also contribute to the fear of getting tested and to mistrust in modern health clinics.

Lastly, Malcolm et al. reported denial or attempted denial of health insurance coverage for PLWHA (Malcolm et al., 2007, pp, 361). The fear that one’s HIV status may influence one’s health insurance coverage, is also acknowledged by the study of

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Duffy. This study reports cases in Zimbabwe where doctors were asked by nurses not to write HIV as a diagnose on a chart or death certificate, as this would affect insurances (Duffy, 2004, pp. 17). Denial of insurance coverage can affect the patients’ financial ability to pay for medical bills and therefore influences the treatment of patients. Furthermore, fear of denial of insurance coverage can lead to delays in test-seeking, refusal of getting tested and denial of HIV status. This can all comprise someone’s health and facilitates the spread of the disease.

1.4. HIV/AIDS-related stigma in South Africa

The Republic of South Africa has more people infected with HIV than any other country in the world (Kalichman et al., 2004, pp. 135). In 2016, 19% of the global number of PLWHA was living in South Africa and 15% of all new HIV infections occurred in the country. South Africa has the largest treatment programme in the world, with 20% of all PLWHA on ART worldwide coming from South Africa. Furthermore, the country has one of the largest domestically funded HIV-programs in the world, with 80% of the HIV-response funded by the South African government (UNAIDS, Country Factsheet South Africa, 2016).

As seen in the second paragraph of this chapter, fears associated with illness, disease and sex need to be viewed in a broader social and cultural context, as each society has their own meaning and explanations for sickness, ideas about disease transmission and sexual behaviour (Malcom et al., 1998, pp. 351). To understand HIV/AIDS-related stigma in South Africa, this stigma needs to be viewed in South Africa’s social and cultural context. Therefore, a deeper understanding of the origins and factors mediating HIV/AIDS-related stigma in South Africa is necessary.

Regarding South Africa’s social and cultural context, the ethnical and cultural diversity of the country needs to be taken into account. South Africa is known for its ethnical and cultural diversity, with many ethnical groups representing their own culture and eleven official languages. At the beginning of the apartheid in 1948, the apartheid regime created four official racial categories: black, coloured, white and Asian/Indian. Although these official racial categories disappeared with the fall of apartheid in South Africa, racial separation and differences are still present in South Africa’s post-apartheid society (Henrard, 2003, pp. 37). In this post-apartheid context, different racial backgrounds can be identified as an origin of HIV/AIDS-related stigma. According to Petros et al., South Africans from different racial backgrounds

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blame each other as being the source of HIV or responsible for the spreading of the disease (2006, pp. 70). They state that white South Africans accuse black South Africans for spreading the disease, coming from higher prevalence rates of HIV in black communities, while black South Africans blame white South Africans for bringing the virus into South Africa (Petros et al., 2006, pp. 70). According to Petros et al., this culture of accusing the other leads to a false sense of security where vulnerability and exposure of the own group is being denied (2006, pp. 71).

Similar to many other countries in Sub-Sahara Africa, religion can be identified as a factor mediating HIV/AIDS-related stigma in South Africa as well. Religion plays an important role in South African society and therefore religion can play a role in both increasing and decreasing HIV/AIDS-related stigma. In many cases, religion binds communities together in South Africa, which can lead to decreased stigma levels (Mbonu et al., 2009, pp. 5). However, these safe spaces and closed environments create a separation between ‘us’ and ‘them’, which can lead to increased stigma levels (Gilmore & Somerville, 1994, pp. 1340). According to Petros et al, religion as perceived safe zones in South Africa leads to denial and distances HIV as a problem that only affects those outside of the own religious space (Petros et al., 2006, pp. 71).

Not only religious beliefs play a role in mediating HIV/AIDS-related stigma in South Africa, traditional beliefs can also lead stigmatisation. A study by Shisana and Simbayi showed that 4% of South Africans belief that HIV is caused by witchcraft and 14% of the South African population is unsure whether HIV is caused by witchcraft or not (2002, pp. 308). The relation between spiritual and supernatural forces and HIV/AIDS-related stigmatisation is demonstrated by a study of Kalichman and Simbayi in Cape Town. Their study showed that people, who believe HIV is caused by spiritual and supernatural forces, were significantly more likely to endorse repulsion and social sanction stigmatising beliefs against PLWHA (Kalichman & Simbayi, 2004, pp. 572).

A fourth factor mediating HIV/AIDS-stigma in South Africa are homophobic tendencies. In South Africa, like in many countries worldwide, HIV-prevalence rates are especially high among men who have sex with men. The prevalence rate among men who have sex with men is 26.8% in South Africa, compared to a national relevance rate of 18.9% (UNAIDS, Country Factsheet South Africa, 2016). A combination of already existing homophobic tendencies and these high prevalence

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rates in South Africa can lead to homosexuality being viewed as a source of HIV/AIDS in South Africa (Petros et al., 2006, pp. 73).

Campbell et al., identify a lack of social spaces to talk about HIV/AIDS as another root of HIV/AIDS-related stigma in South Africa. According to them, the majority of South Africans heard about HIV/AIDS though an impersonal source, rather than from personal sources (Campbell et al., 2007, pp. 409). This can cause a lack in social spaces in which people feel safe to discuss the topic of HIV/AIDS. When information about HIV/AIDS is only acquired form impersonal sources, this can create a distance and HIV/AIDS can therefore be viewed as an issue that only affects others.

The last factor mediating HIV/AIDS-related stigma can, similar to many Sub-Saharan societies, be found in gender. In South Africa HIV-prevalence rates are higher among women than among men. In 2016, 23.8% of women aged 15 to 49 were HIV-positive in South Africa, opposing to 14.2% of men in the same age group. The prevalence rate among young women was 10,4% in 2016, while the prevalence rate among young men was 4% (UNAIDS, Country Factsheet South Africa, 2016). According to Petros et al., these high prevalence rates among women contribute in some cases to stigmatisation of women as being sexually promiscuous, loose, prostitutes, dirty or immoral (2006, pp. 72). Furthermore, stigmatisation in South Africa is strengthened by women’s lower socio-economic status and their lower socio-economic status, intertwined with unequal power-relations in the country (Malcolm et al., pp. 357).

The need to reduce HIV/AIDS-related stigma in South Africa is specifically addressed in South Africa’s strategic national plan for HIV, TB and STI’s 2017-2022. Before the development of the strategic plan, a survey was held under 1000 PLWHA. This survey showed that 35,5% of PLWHA reported experienced stigma (SANAC, 2016, pp. XVII). One specific goal of the strategic plan is to reduce this stigma and discrimination of PLWHA by half by 2020. The aim is to reduce public stigma through the revitalisation of community-based support groups to deal with internalised stigma and through community education (SANAC, 2016, pp. 32). The Department of Education is promoting HIV/AIDS education in public high schools, particularly though the subject Life Orientation.

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1.5. Stigma-reducing strategies and interventions

As mentioned in the introduction, reducing the existing stigma surrounding HIV/AIDS is crucial in the fight against the epidemic. This recognition has led to new stigma-reducing strategies and many new stigma-reducing interventions worldwide. These interventions have different goals, which are intertwined with the target group of the intervention. Brown et al. distinguish three different goals of stigma-reducing interventions in the area of HIV/AIDS in their review study. The first goal they distinguish is to increase tolerance of PLWHA among segments of the general population. These interventions are usually performed in educational environments, like schools or universities, or within specific communities. The second intervention goal that can be distinguished is to increase the willingness to treat PLWHA among health care providers. Naturally, these interventions are performed in medical environments, like hospitals or health clinics. The third intervention goal Brown et al. describe is to improve coping strategies for dealing with HIV-stigma among those at-risk or already infected with HIV. These interventions are usually performed in counseling environments or support groups. (Brown et al., 2003, pp. 53). When analyzing studies on specific stigma-reducing interventions, a fourth intervention goal can be distinguished, which is not taken into account by the study of Brown et al. This is the goal to improve coping strategies among people living close to PLWHA. Examples of interventions with this goal are the interventions studied by Chidrawi et al., Kaleeba et al., and Prinsloo et al (Chidrawi et al, 2016, Kaleeba et al., 1997 & Prinsloo et al., 2017). These interventions usually take place in support groups, counseling environments or within specific communities.

As these different interventions all have specific goals and specific target groups, they are implemented at different levels, each level requiring different strategies. Heijnders & Van der Meij distinguished five different five levels in which interventions aimed to reduce HIV/AIDS-related stigma can be implemented, including corresponding strategy examples, as given in Table 1.

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Table 1. Stigma-‐reduction strategies (Heijnders & Van der Meij, 2006, pp. 354)

Level Strategies

Intrapersonal level Treatment Counselling

Cognitive – behavioural therapy Empowerment

Group counselling

Self-help, advocacy and support groups Interpersonal level Care and support

Home care teams

Community-based rehabilitation Organizational/institutional level Training programmes

(New) policies, like patient-centred and integrated approaches Community level Education

Contact Advocacy Protest

Governmental/structural level Legal and policy interventions Rights-based approaches

According to Heijnders & Van der Meij, ‘interventions at the interpersonal level aim at modifying the affected person’s environment. These interventions deal with the impact of social support and social networks on health status and behaviors. They aim to establish relationships between members of the patients’ interpersonal environment in order to have them share ways to restore or promote their health.’ (2007, pp. 356). Therefore, interventions on the personal levels are interventions with the goal to improve coping strategies and increase tolerance to PLWHA among people living close to them or interventions to increase willingness to treat PLWHA among health care providers.

Interventions on the intrapersonal level have a primary focus on individual behaviour change, by knowledge building, improving self-esteem, improving coping skills, empowering and providing economic support (Heijnders & Van der Meij, 2007, pp. 355). These interventions are usually focused on internalized stigma and usually have the goal to improve coping strategies for dealing with HIV-stigma among those at-risk or already infected with HIV.

The focus of interventions at the organisational or institutional level is on organisational change to modify health and stigma-related aspects of an organisation (Heijnders & Van der Meij, 2007, pp. 357). The goal of interventions on this level can fall under the category ‘to increase tolerance of PLWHA among segments of the

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general population.’ as the employees of these specific organisations and can be defined as ‘segments of the general population’.

According to Heijnders & Van der Meij, interventions at the community level increase knowledge regarding specific health conditions and regarding stigma within specific community groups. They also increase community development skills, to develop support networks and through these, provide better access to services for people affected (2007, pp. 358). These interventions can be categorized as ‘interventions to ‘to increase tolerance of PLWHA among segments of the general population’ or ‘interventions to improve coping strategies among people living close to PLWHA’.

Lastly, interventions at the governmental and structural level enforce the protection of rights of people affected with a stigmatizing illness. Laws and policies developed on governmental level create acceptance through normalization and thus increase tolerance of PLWHA among segments of the general population. However, depending on their focus area, can also increase willingness to treat PLWHA among health care providers.

Besides a categorization of intervention goals, Brown et al. also developed a categorization of intervention types. As seen from Table 2, they distinguish interventions with an information-based approach, interventions focused on skills building, interventions with a counselling approach and interventions that facilitate contact with affected groups (Brown et al., 2003, pp. 53). Not all the strategies mentioned by Heijnders & Van der Meij fall under one of these categories, as law and policy making on the governmental or organisational level, is neither an information-based approach, skills building, a counselling approach or a facilitator of contact with affected groups. Therefore there can be argued that the categorization of Brown et al. should be extended with a law- or policymaking approach.

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Table 1. Types of interventions (Brown et al., 2003, pp. 53)

Type Information-based

approaches

Skills building Counselling

approaches

Contact with affected groups

Definition Fact-based information, written and/or verbal communication

Learning strategies for resolving negative attitudes

Providing support for

positive behaviour Interaction between affected groups and general public Examples - Written information

- Video - Classroom-type factual presentation - Media advertisements - Peer education - Guided group discussions - Role-play - Master imagery - Reframing and relaxing techniques - Group desensitization - Scripting - One-on-one counselling - Support groups -‐ Live testimonials - Interaction with PLWHA - Visualisation of being a PLWHA

1.6. Entertainment Education as a stigma-reducing strategy

This thesis aims to examine the effectiveness of one specific intervention aimed to reducing HIV/AIDS-related stigma, namely the television series MTV Shuga. As this intervention can be defined as an Entertainment Education intervention, a broader understanding on Entertainment Education as a stigma-reducing strategy is needed to examine the effectiveness of MTV Shuga on HIV/AIDS-related stigma.

Singhal & Rogers define Entertainment Education as “process of purposely designing and implementing a particular media message to both entertain and educate in order to increase knowledge about a social issue, create favourable attitudes and perceptions and change their overt behaviour regarding the social issue (2002, pp. 127). Therefore, there can be stated that Entertainment Education involves pro-social messages that are embedded into popular entertainment context (Booker et al., 2016, pp. 1437). This popular entertainment context can be television, radio, theatre, literature, social media and other media to alter consumers’ attitudes and behaviours in desirable ways by embedding persuasive messages in the narrative (Murrar & Brauer, 2017, pp. 1). In Sub-Saharan Africa, the most common forms of Entertainment Education are radio and television drama (Booker et al., 2016, pp. 1437). These forms have been used to address a wide range of social issues such as unsupported population growth, gender inequality, different health issues and environmental pollution (Vaughan et al., 2012, pp. 82). Related to HIV/AIDS-issues, studies have been conducted on the effectiveness of Entertainment Education as a strategy to promote HIV/AIDS-prevention and control. These studies suggest that

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Entertainment Education, through its use of formative research, audience segmentation, a multimedia campaign approach, media celebrities and other creative techniques such as humour and animation, can be highly effective in promoting HIV/AIDS-prevention and control (Vaughan et al., 2012, pp. 82). Besides promoting prevention and control, Entertainment Education interventions have also been used as a strategy to reduce HIV/AIDS-related stigma. However, limited research has been done on the effectiveness of these interventions in reducing stigma. Over the years, researchers have used different theoretical models to explain the potential effects of Entertainment Education and the mechanisms by which it can influence beliefs, attitudes and behaviours. The first model is identified by Murrar & Brauer. According to them, the effectiveness of Education Education can be found in the Intergroup Contact Theory. This theory states that direct contact between individuals belonging to different social groups is one of the most effective ways to reduce hostile intergroup feelings. Interacting with and getting to know members of an outgroup allows people to relate to the outgroup more, extend their sense of self to that outgroup, understand the perspectives of an outgroup member and identify closely with the outgroup (Murrar & Brauer, 2017, pp. 3). According to this theory, interacting with PLWHA would be the ideal strategy to reduce stigma. However, this is not always possible and sometimes even actively avoided. PLWHA are often hesitant to disclose their status or to talk about their status in public due to anticipated stigma. Therefore, interventions that facilitate interaction between PLWHA and the general public are not always possible. Entertainment Education can be the alternative for direct contact, as it can facilitate a one-sided personal relationship with an outgroup or character in the media (Murrar & Brauer, 2017, pp. 3). By doing so, Entertainment Education can be a method to understand the perspectives of the outgroup, feel similar and more connected to the outgroup and identify more with the outgroup. This can lead to a reduction in stigma levels. Two other theoretical models that explain the potential effectiveness of Entertainment Education are identified by Shen & Han (2014). The first method they describe is the Social Cognitive Theory (SCT). This theory also underlines the effect of Entertainment Education as a strategy to increase identification with an outgroup, but additionally it suggest that this closer identification leads to attention, memory and modelling behaviours. According to this theory, individuals who identify themselves with other individuals or fictional characters are more likely to model

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behaviours and attitudes (Shen & Han, 2014, pp. 606). In this way, Entertainment Education can change the behaviour and attitudes of audiences by creating characters with favourable behaviour and attitudes.

The second theoretical model described by Shen & Han is the Extended Elaboration Likelihood Model (EELM). This model considers identification with characters and transportation into storylines as potential variables mediating the effects of Entertainment Education narratives. The model states that transportation into narratives can reduce counter-arguing. Thus, when persuasive information is embedded in Entertainment Education narratives, viewers will be absorbed in storylines and as a result, do not have the motivation to engage in counter-arguing with the persuasive narrative of the storyline (Shen & Han, 2014, pp. 606).

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2. Research objective and Method

As stated in the previous paragraph, the most common forms of Entertainment Education in Sub-Saharan Africa have been television and radio dramas. Among these efforts is the television series MTV Shuga. This thesis aims to examine the effectiveness of MTV Shuga in reducing HIV/AIDS-related stigma among, university students, high school students and school drop-outs in Cape Town, South Africa. 2.1. MTV Shuga

MTV Shuga is a television series developed as part of MTV Staying Alive, an initiative to encourage HIV prevention, promote safer lifestyle choices and to fight the stigma and discrimination fuelling the HIV epidemic. This is done through global transmedia campaigns on HIV and sexual and reproductive health. Their campaigns are aimed to build an empowered and educated generation of young people, equipped with the tools and knowledge to protect themselves and their peers from the HIV epidemic. Most of their campaigns make use of media content carrying out a HIV and sexual and reproductive health message to a global audience (MTV Staying Alive Foundation, 2016, pp. 3).

One of the campaigns by the MTV Staying Alive Foundation is the television drama MTV Shuga. MTV Shuga was developed to improve sexual and reproductive health among young people, by addressing several social issues such as safe sex, HIV-testing, HIV-stigma, teenage pregnancies, sexual violence, LGBT-stigma, economic empowerment and the importance of education. The first season was broadcasted in November 2009, followed by five more seasons in the period of 2011 till 2018. The first two seasons were recorded in Kenya. Season 3 and 4 took place in Nigeria and season 5 in South Africa. Season six, which was broadcasted early 2018, was again recorded in Nigeria. All the seasons together have reached over 720 million people worldwide and were broadcasted on 179 channels worldwide, including in 96% of the countries in Sub-Saharan Africa (MTV Staying Alive Foundation, 2016, pp. 28). Several studies have been conducted on the effectiveness of MTV Shuga on safer sex practices and testing behaviour. A study conducted by the University of the Western Cape showed that the number of people who would never use a condom dropped from 16% to 7% after watching the series. A randomized cluster study conducted among young people in Nigeria showed that people who watched MTV

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Shuga were 35% more likely to be tested in the past two months (MTV Staying Alive Foundation, 2016, pp. 28). However, no studies have been conducted on the effectiveness of MTV-Shuga in reducing HIV/AIDS-related stigma.

For this thesis, the effectiveness of MTV Shuga season 4 on reducing HIV/AIDS-related stigma will be examined. Season 4 primarily revolves around the storylines of five characters:

1. The storyline of Femi

Femi is a fictive popular Nigerian DJ and producer, who is HIV-positive. Femi is in a relationship with Sheila. Sheila is HIV-negative and fully supportive to Femi and his personal issues related to his HIV-status. At the start of the season, Femi has not disclosed his status to the general public, nor to the family of Sheila. Sheila decides it is time to disclose Femi’s HIV-status to her family at a dinner. However, before they can raise the topic of Femi’s HIV-status, the conversation topic changes to PLWHA and Sheila’s family starts to make fun of PLWHA. Later on, an acquaintance of Femi and Sheila spots Femi while he is picking up his ART-medication at the health clinic. This acquaintance is under the impression that Sheila is not aware about Femi’s status and confronts Sheila. Sheila’s brother overhears this conversation and makes negative statements about Femi. Sheila defends her boyfriend and storms off. Sheila goes back to her family’s house to talk about Femi’s HIV-status with the rest of the family. The response of her family is very negative and her father even forbids her to marry Femi. Femi and Sheila still decide to disclose Femi’s status to the general public during a television interview. The responses to this interview are overwhelming, with many fans expressing their support for the couple. With his public disclosure, Femi breaks the taboo on HIV/AIDS and the couple becomes a role model for other PLWHA.

2. The storyline of Weki

Weki is a high school boy, who was infected with HIV at birth. He is in a relationship with Leila, who is not aware of his HIV-status. Weki wants to disclose his status to Leila, however he is too afraid to tell her. When Weki and Leila have sex for the first time, Weki feels guilty of not telling Leila, despite the fact they used a condom. One day, Leila spots Weki at a support group for PLWHA and finds out about his HIV-status. Leila is furious at Weki for not telling her and at the same time really afraid that she might have HIV as well. Weki is filled with guilt and ensures Leila she

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cannot be HIV-positive, as they used a condom. Leila gets tested for HIV and turns out to be HIV-negative. At the end of the season, Leila forgives Weki and they end up back together.

3. The storyline of Princess

Princess is an HIV-positive girl who got pregnant unexpectedly, not exactly knowing who to father of the baby is. Princess struggles to cope with her recent HIV-diagnose and with her unexpected pregnancy. She considers giving her baby up for adoption, but decides not to so once the baby is born. At the beginning of the season, Princess is really afraid that her baby will be HIV-positive as well. Therefore, her sister Sophie arranges a meeting with an HIV-positive mother, whose children are not infected with HIV. Princess learns that when she is taking her medication consistently, she will not transfer the virus to her baby at the delivery and when breastfeeding.

4. The storyline of Mary

Mary is a young high school girl, who might have to quit school, as her parents are not able to pay the school fees anymore. One day, she meets the rich Ghanaian businessman Nii. He tells her he is impressed by her and takes her to nice restaurants, buys new clothes for her and even offers to pay her school fees. Mary’s parents are not happy about the contact Mary and Nii have, because of the huge age difference and because they fear Nii has bad intentions with Mary. They agree on meeting Nii and eventually agree on him paying Mary’s school fees as a loan. At some point, Mary decides that she wants to lose her virginity to Nii. However, when Nii makes a move on her, she decides she does not want to sleep with him and she asks him to bring her home. Nii gets furious about Mary’s rejection and he starts beating her up. At the end of the season, Nii gets arrested, as Mary’s mother reported him to the police.

5. The storyline of Sophie

Sophie is a beautiful and open-minded girl who does voluntary work at an HIV helpline. Because of her work, Sophie has a lot of knowledge about sexual and reproductive health and HIV-related issues. Sophie is in a relationship with the handsome Leo. They are considered as the perfect couple, both very beautiful and living the good life in Lagos. Sophie decided that she wants to wait with sleeping with

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Leo. Leo respects this decision initially, but loses himself after a night of heavy drinking. He forced himself onto her and only stopped when Sophie started screaming. After this incident, Sophie did not want to see Leo anymore.

As seen from these five different storylines, several social issues addressed in MTV Shuga season 4 can be distinguished, such as HIV-testing, being diagnosed with HIV, being in a relationship with someone who is HIV-positive, HIV-stigma, disclosure of HIV-status, taking ART, sexual abuse, violence, unexpected pregnancy, condom use, sleeping with someone for the first time, poverty and sugar daddies. The reason why season 4 has been chosen for this research lies in the social issues being addressed and the narrative of this season. As seen from the previous chapter, it is assumed that Entertainment Education can create favourable perspectives, attitudes and behaviour of audiences, by embedding pro-social messages in the narrative. As the effectiveness of an Entertainment Education intervention on reducing stigma levels is examined in this study, the favourable perspectives, attitudes and behaviour must be reflecting reduced stigma levels. This can only be achieved if pro-social messages about HIV-stigma, PLWHA and HIV in general are embedded in the narrative. In season 4 of MTV Shuga, these messages are clearly embedded in the storylines of Femi and Weki, but also in the storylines of Princess and Sophie. Princess shows that there are ways to cope with an HIV-diagnose and that someone who is HIV-positive can give birth to healthy children. These messages can potentially reduce HIV/AIDS-related stigma. The storyline of Sophie can potentially reduce stigma, because of the open-mindedness and supportiveness of her character in the conversation she has at the HIV helpline and the way she tries to support and educate her sister Princess.

Although the stigma-reducing messages in the narrative of season 4 are clear, there could be argued that season 5 would be suitable for this study as well, because of the target groups of this study. The target groups of this study are South African university students, high school students and school dropouts and season 5 of MTV Shuga is recorded in South Africa, with a storyline focussing mainly on South African characters. Therefore, there can be argued that the target groups of this study would be able to identify closer to the characters and the storyline of season 5. However, although season 5 also focuses on HIV-related issues, these issues are less stigma-related. For this reason, season 4 is the most suitable season to use for this study, despite the location of recording and the location used in the storyline.

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2.2. Research objective

The aim of this thesis is to examine the effectiveness of MTV Shuga in reducing HIV/AIDS-related stigma, according to the following research question: ‘What is the effect of MTV Shuga season 4 on HIV/AIDS-related stigma among university students, high school students and school dropouts in Cape Town, South Africa?’ In answering this research question, eight specific objectives of this study can be distinguished. These objectives are:

1. To examine the level of HIV/AIDS-related public stigma among university students, high schools students and school dropouts in Cape Town, before watching MTV Shuga season 4

2. To examine the level of HIV/AIDS-related experienced stigma among university students, high schools students and school dropouts in Cape Town, before watching MTV Shuga season 4

3. To examine the level of HIV/AIDS-related anticipated stigma among university students, high schools students and school dropouts in Cape Town before watching MTV Shuga season 4

4. To examine the intended behaviour of university students, high school students and school dropouts in Cape Town towards PLWHA, before watching MTV Shuga season 4

5. To examine the change in the level of HIV/AIDS-related public stigma among university students, high school students and school dropouts in Cape Town, after watching MTV Shuga season 4

6. To examine the change in the level of HIV/AIDS-related anticipated stigma among university students, high school students and school dropouts in Cape Town, after watching MTV Shuga season 4

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7. To examine the change in intended behaviour of university students, high school students and school dropouts in Cape Town towards PLWHA, after watching MTV Shuga season 4

8. To identify the perspectives of university students, high school students and school dropouts in Cape Town on the effectiveness of MTV Shuga season 4 as a tool to reduce HIV/AIDS-related stigma

2.3. Scientific and societal relevance

As seen from the introduction, the effectiveness of HIV/AIDS-related interventions focussed on knowledge building and promoting preventive behaviour are widely researched upon. However, limited research has been done on the effectiveness of interventions aimed at reducing HIV/AIDS-related stigma. For this reason, several scholars have defined the lack of studies examining specific interventions aimed at reducing related stigma as a gap in the research regarding HIV/AIDS-related stigma and HIV/AIDS-HIV/AIDS-related interventions (Brown et al., 2003, Heijnders & Van der Meij, 2007 & Sengupta et al., 2011). This thesis aims to contribute in overcoming this research gap by examining the effectiveness of one specific intervention aimed at reducing HIV/AIDS-related stigma: MTV Shuga season 4.

A second research gap is identified in the previous chapter, which is related to Entertainment Education. The effectiveness of Entertainment Education as a tool for knowledge building and behaviour change has been widely researched upon (Do & Kincaid, 2006, Mckee, 2012, Nyambane et al., 2015 & Wilkin et al., 2007). Related to the topic of HIV/AIDS, this has led to several studies examining the effectiveness of Entertainment Education on HIV/AIDS-prevention, control and communicating health information (Booker et al., 2016, Shen & Han, 2014, Sood et al., 2006, Vaughan et al, 2000 & Vaughan et al., 2012). However, research on the effectiveness of Entertainment Education in reducing stigma is scarce, despite the fact that Entertainment Education has been used as a stigma-reducing strategy. Three existing studies focussing on the effectiveness of Entertainment-Education on reducing prejudices, stereotypes and stigma can be identified, of which the study of Sallar & Somda specifically focusses on Entertainment Education as a tool to reduce

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HIV/AIDS-related stigma (Gesser-Edelsburg & Endevelt, 2001, Murrar & Brauer, 2017 & Sallar & Somda, 2011). This limited amount of studies specifically focussed on the effectiveness of Entertainment Education in reducing stigma, and more specifically in reducing HIV/AIDS-related stigma, indicates a research gap in this area. This means that the potential of Entertainment Education as a stigma-reducing strategy has not been assessed extensively yet. This study contributes in overcoming this research gap as well, as it examines the effectiveness of one specific Entertainment Education intervention in reducing stigma.

Besides the scientific relevance, a societal relevance of this study can be identified as well. As seen from the introduction, reducing stigma related to HIV/AIDS is essential in the fight against the epidemic. It is therefore important that programmes and interventions regarding HIV/AIDS are not focussed on education, promoting preventive behaviour and promoting testing behaviour, but also on reducing HIV/AIDS-related stigma. As the need of reducing stigma in the fight against the epidemic has become widely recognized in the last decade, interventions and strategies aimed at reducing HIV/AIDS-related stigma has been developed and implemented worldwide. However, to really make an impact, the effectiveness of these different strategies and interventions need to be examined. By doing so, the successful and less successful interventions and the successful and less successful aspects of these interventions can be identified. In this way, future inventions can benefit from the lessons learned from past interventions and new, effective interventions can be created. This study will contribute to identifying successful and less successful elements of a stigma-reducing intervention and therefore indirectly contribute to the development of new, effective interventions. When more effective interventions will be implemented, the stigma levels within communities and, more generally, within society will gradually decrease. Decreasing levels of HIV/AIDS-related stigma within communities and society can, as seen from the previous chapter, improve the quality of life of PLWHA and counter negative public health outcomes enhanced by stigma.

2.4. Method and research design

This study makes use of a mixed method approach, combing a survey to gather data for quantitative data analysis and focus group discussions for qualitative data analysis. For this study a specific research design is chosen, namely the sequential explanatory

Stigma Reduction through Entertainment Education: The effectiveness of MTV Shuga on reducing HIV/AIDS-related stigma among university students, high school students and school dropouts in Cape Town, South Africa