Improving youth sexual health through educational entertainment

Practicing safe sexual behaviors can reduce the transmission of HIV and other sexually transmitted infections (STIs), yet many campaigns to encourage safe sex have struggled to shift young people’s behaviors in regions where HIV is prevalent. The MTV Staying Alive Foundation partnered with researchers to evaluate whether the educational television drama series, MTV Shuga, changed attitudes and behaviors related to interpersonal health and HIV among young viewers in Nigeria. 

The study found that viewers who watched Shuga were more likely to get tested for HIV, less likely to test positive for other sexually transmitted infections, and more knowledgeable about safe sex. The MTV Staying Alive Foundation used the results to further tailor the messaging presented in Shuga, raise funding for subsequent seasons in Nigeria and beyond, and spur additional research as part of a commitment to continuous learning and adaptation. 

The Problem

Practicing safe sexual behaviors can reduce the transmission of HIV and other STIs, yet many public campaigns to encourage safe sex have struggled to shift young people’s behaviors in regions where HIV is prevalent.

Approximately 40 million people around the world, roughly two-thirds of them in sub-Saharan Africa, are living with HIV.¹ It is estimated that there were 660,000 new HIV infections in sub-Saharan Africa in 2022 alone. Over the past two decades, governments and international organizations have invested in increasing access to antiretroviral medications and raising awareness of HIV prevention.² Nevertheless, awareness of HIV prevention and treatment remains low among young adults, who are the most likely to be exposed to the virus. 

In 2012, the year before the study began, around 24 percent of Nigerian youth aged 15 to 24 could identify ways to prevent the sexual transmission of HIV, and 17 percent of adults and older adolescents aged 15 to 49 had been tested for HIV.³ Many behavioral interventions aimed at reducing HIV, including information interventions, voluntary counseling and testing, and classroom-based education, have been unable to meaningfully reduce the transmission of HIV and other STIs. Delivering educational messages through entertaining media, known as edutainment. 

The MTV Staying Alive Foundation, a media initiative that aims to educate young people about sexual and reproductive health, mental health, and gender-based violence, launched the edutainment television series Shuga in 2009. The series was designed to raise awareness about HIV/AIDS and promote safe behavior. The first season, set and filmed in Kenya, consisted of three episodes that told the story of a young woman, played by award-winning actress Lupita Nyong'o, balancing her future ambitions with a relationship, both of which are put in jeopardy by her involvement with an older man. The short series was well-received by audiences and attracted international attention from organizations interested in using entertainment to teach young people about HIV.  

Encouraged by Shuga’s positive initial reception, the foundation sought rigorous evaluation to determine whether the program was achieving its educational and behavior change goals. 

The Research

Shuga increased young viewers’ knowledge about HIV, increased testing rates, and reduced the stigma viewers held around those with HIV.

The MTV Staying Alive Foundation partnered with J-PAL affiliated researchers Abhijit Banerjee and Eliana La Ferrara, together with Victor Orozco of the World Bank’s Development Impact (DIME) department, to conduct a randomized evaluation testing the impact of Shuga on young people’s knowledge, attitudes, and behavior toward HIV and risky sex. The evaluation built on previous surveys conducted by researchers at Johns Hopkins University—which suggested that young people who watched the first seasons of Shuga in Kenya had positive perceptions of both HIV testing and community members living with the virus—and aimed to confirm whether Shuga’s messaging led to those impacts. 

Researchers evaluated the third season of Shuga, filmed in Lagos, Nigeria in 2013. The season consisted of eight 22-minute episodes, which presented stories about the stigma and discrimination associated with the virus, dispelled myths related to HIV transmission, and included messages promoting HIV testing and discouraging risky sex. While writing the scripts, MTV Staying Alive Foundation conducted a series of focus groups with young people around Lagos to ensure that the series focused on the issues that were most relevant to them. 

Researchers recruited 4,986 young adults between the ages of 18 and 25 from seven towns in South-West Nigeria to attend two 90-minute screening sessions, held at local community centers and schools. 26 randomly selected screening sites showed a non-educational television series, 27 sites showed Shuga, and an additional 27 sites paired Shuga screenings with additional content on the values and beliefs of their peers.

Results of the evaluation showed that watching Shuga increased viewers’ knowledge about HIV and improved their sexual health. Participants who watched Shuga were more likely to report being tested for HIV and more likely to be aware of good HIV testing protocol (waiting three months between tests to confirm results). Women who watched Shuga were also less likely to test positive for chlamydia, another STI, compared to women who did not. Shuga increased viewers’ awareness of methods for HIV transmission and options for treatment, reduced negative attitudes about community members with HIV, and made viewers less likely to report having multiple concurrent sexual partners. Watching additional content on the beliefs of other community members had no additional impact on attitudes about HIV.

The evaluation also showed that subtle messaging around secondary issues was less effective at shaping participants’ attitudes and behaviors than the more explicit messaging around HIV testing and attitudes. For example, brief mentions of the importance of condom use to prevent the transmission of STIs did not translate into increased condom usage among viewers. Men who viewed the program, which featured a subplot about intimate partner violence (IPV), were less likely to justify violence. However, some viewers became more sympathetic to a wealthy and attractive character who committed IPV. 

Based on the reduced rate of chlamydia among women who watched Shuga, the World Bank estimated that every US$1 invested in Shuga could result in up to US$150 worth of health benefits to viewers. 

Researchers suggest that participants’ ability to identify with the characters and engage with the plot could explain why Shuga had a greater impact than previous more traditional behavioral interventions. 

For more details, see the evaluation summary.

From Research to Action 

MTV Staying Alive Foundation has drawn on lessons learned from the randomized evaluation and other research to raise funding, adapt messaging, and scale the Shuga franchise to viewers across 72 countries.

The results of the evaluation bolstered MTV Staying Alive Foundation’s efforts to bring the program to more youth across more geographies. MTV produced three more seasons of Shuga in Nigeria, two in South Africa, and two in Côte d’Ivoire. Over two million viewers tuned in weekly to the most recent season set in South Africa. 

Rigorous evidence of the program’s impact helped the MTV Staying Alive Foundation leverage funding to expand the franchise. In 2021, MTV received a US$675,000 grant from the Global Innovation Fund—which cited the evaluation as evidence of the program’s effectiveness at reducing STIs among viewers—to produce new seasons of Shuga in Nigeria and South Africa and to launch a new series in India. 

The foundation also used the findings of the evaluation to tailor the content presented in future seasons of Shuga. Seeing that educational messages presented in subplots did not affect viewers' behaviors, such as using condoms, writers of future seasons were encouraged to make the educational content central to the main plot and to ensure that the messaging would be relevant to the audience.

The randomized evaluation also strengthened the MTV Staying Alive Foundation’s commitment to continuously monitoring the program’s impacts in an iterative learning cycle. Additional studies using a variety of different research methods have since found that Shuga had positive impacts on viewers’ attitudes around intimate partner violence, awareness of contraception, and awareness of HIV prevention measures in Nigeria and South Africa. 

In 2022, MTV Staying Alive Foundation announced plans to bring Shuga to the United States with a new season set in Baltimore focusing on young people in communities navigating gentrification. It also produced a spin-off series, MTV Nishedh, set in India, which contains messages around nutrition and infectious disease stigma and prevention in addition to sexual health, and a web series, Shuga: Alone Together, which focused on Covid-19. Shuga and its spin-offs have now aired in 72 countries and reached viewers in more than 720 million households. 

The evaluation of MTV Shuga was among the first impact evaluations of an edutainment program and has influenced researchers and practitioners in using entertainment to inspire behavior change. The intervention was pivotal to the World Bank’s decision to launch its research program on entertainment education in 2016, a collaboration between researchers, development agencies, media firms, and governments led by Victor Orozco, one of the researchers involved in the evaluation. The World Bank has since conducted randomized evaluations of television shows, films, social media campaigns, and games aimed at addressing literacy, test scores, savings, and financial planning, among others.
 

References

Banerjee, Abhijit, Eliana La Ferrara, and Victor Orozco. 2019. “The Entertaining Way to Behavioral Change: Fighting HIV with MTV.” NBER Working Paper No. 26096. https://www.nber.org/papers/w26096

Banerjee, Abhijit, Eliana La Ferrara, and Victor Orozco. 2019. “Entertainment, Education, and Attitudes Toward Domestic Violence.” AEA Papers and Proceedings, 109: 133-37. https://doi.org/10.1257/pandp.20191073 

Banerjee, Abhijit, Eliana La Ferrara, and Victor Orozco. 2018. “The entertaining way to behavioural change: Fighting HIV with MTV in Nigeria.” VoxDev. https://voxdev.org/topic/health/entertaining-way-behavioural-change-fighting-hiv-mtv-nigeria 

Hanifnia, Kathi and Rachna Nag Chowdhuri. “MTV Shuga Shows that ‘Edu-tainment’ Changes Lives.” Global Innovation Fund: News, November 11, 2022. https://www.globalinnovation.fund/news/our-innovations/mtv-shuga-shows-that-edu-tainment-changes-lives

Kharsany, Ayesha BA and Quarraisha A. Karim. 2016. “HIV Infection and AIDS in Sub-Saharan Africa: Current Status, Challenges and Opportunities.” The Open AIDS Journal. 8, no. 10 (April): 34-48. https://doi.org/10.2174/1874613601610010034 

MTV Staying Alive Foundation. “Lightning talks: Evidence from evaluations of MTV Shuga,” https://cdn.sanity.io/files/5lp3a2r6/production/a4c432642f72261b321b446748e99832a8103733.pdf

MTV Staying Alive Foundation. “New research finds young people’s positive changes in behaviour are significantly linked to watching sex edutainment content by MTV Staying Alive Foundation,” October 21, 2021. https://cdn.sanity.io/files/5lp3a2r6/production/dd16fb510867c8011d2e478ab4476789de079622.pdf

Padian, Nancy S., Sandra I. McCoy, Jennifer E. Balkus, and Judith N. Wasserheit. “Weighing the Gold in the Gold Standard: Challenges in HIV Prevention Research.” AIDS 24, no. 5 (March): 621-635. https://doi.org/10.1097/QAD.0b013e328337798a 

Singh, Maanvi. “Watch The MTV Soap Opera That Is Secretly Teaching Sex Ed.” NPR, April 18, 2017. https://www.npr.org/sections/goatsandsoda/2017/04/18/522869551/watch-the-mtv-soap-opera-that-is-secretly-teaching-sex-ed