Tuesday, December 14, 2010

A Critique of the Scrutinize Campaign in South Africa – Greg P


The Scrutinize campaign, created by Johns Hopkins Health Education in South Africa (JHHESA) aired on South African television from June 2008 - June 2009. Eleven 15-60 second animated television advertisements targeted young adults (18-32 years). With support from the Levi’s Red for Life initiative and major funders including USAID and PEPFAR, the spots aired with great frequency. An estimated 6.7 million people between the ages of 18-32 years saw the campaign advertisements repeatedly. By one estimate, the advertisements reached 98% of its target audience with an average of 90 viewings per person. The campaign also included a peer education component, radio events, a Facebook group, and merchandise, including popular Levi’s Scrutinize campaign t-shirts (1).
JHHESA and the private sector communications firm Matchboxology designed the television spots to convey an irreverent and humorous take on HIV prevention. Animated characters, inspired by South Park and the Simpsons, were voiced by South African celebrities, including a comedian in the main role. The spots were designed to be a fresh, new take on HIV prevention communications in order to create buzz and stimulate conversation among young adults abouth the various HIV prevention messages conveyed. Creators intended for the situations encountered by the animated characters to be realistic, with dialog “peppered with slang and streetwise expressions.” The main goals of the campaign were to reduce the prevalence of concurrent partnerships, to delay the beginning of sexual activity, to increase the rates of correct and consistent condom use, and to increase rates of HIV testing (1).
The irreverent and humorous approach is central to each advertisement. When a character makes a decision that will result in a risky sexual encounter, a small monster-like character referred to in campaign materials as the “HIV Ninja” sneaks into view and physically attacks the risk-taking character. The HIV Ninja lurks in each scene, ready to strike a new victim. Typically, the main character, Victor Scrutinize, concludes the advertisement by delivering an HIV prevention message such as “Use condoms every time” and states the campaign’s tagline, “Let’s turn HIV into H-I-victory” (2).

Critiques of the Scrutinize Campaign

Creators of the Scrutinize campaign neglect several key aspects of social psychology in their mass media messaging. By failing to properly use advertising theory, treating sexual behaviors as if they are planned, and failing to consider structural factors that underlie sexual risk-taking among South African youth, creators of this intervention have limited this well-funded campaign’s potential for effectiveness.

Critique I: Scrutinize Fails to Engage the Audience on an Emotional Level

Social campaigns resembling for-profit product campaigns are more likely to be effective at producing the desired behavior than social campaigns that ignore advertising principles established in the for-profit sector (3). An applicable concept from for-profit marketing is the “force” toward the desired goal. The force is “the intensity of the person’s motivation toward the goal as a combination of his predisposition prior to the message and the stimulation of the message” (3). A well-established advertising technique to increase a viewer’s motivation to perform a behavior involves centering and advertising campaign around a universal emotional appeal.
A fundamental flaw of the Scrutinize campaign is the lack of an emotional appeal. Each advertisement concludes with the tagline, spoken or written, “Let’s turn HIV into H-I-victory.” The content of the advertisements makes it clear that this slogan is intended only in the context of HIV prevention rather than the context of living with HIV. “H-I-victory” is thus achieved when individuals without HIV avoid HIV infection. The Scrutinize campaign is thus selling the status quo. Desire for the status quo is certainly not likely to inspire widespread behavior change.
By taking an irreverent approach to HIV prevention messaging, the Scrutinize campaign advertisements are not designed to evoke emotion. The animations are fast-paced in a flashy style of quickly changing scenes. Although several characters appear in more than one advertisement, few receive names. The advertisements do not follow a continuous narrative that could make the viewer emotionally committed to the well-being of the characters. Acquiring HIV is not portrayed as a sad event. No support is provided to inspire the viewer to aspire to a life without HIV as no benefits of remaining HIV-negative are portrayed (2).
By using animation rather than people in the advertisements, the creators of the Scrutinize campaign are limited their ability to reach viewers on a less rational, more emotional level. A study by Small and Verrochi (2009) on the imagery used in advertisements of an organization seeking donations supporting children’s cancer research found that emotions can be transferred in a “contagious” manner. The expression on children’s faces had a significant impact on the viewers’ mean donation. While this study examined the effect of emotion in the context of sympathy-evoking advertisements, the authors’ conclusion that “emotion expression matters most when people are thinking with their hearts and not scrutinizing information” illustrates the missed opportunity of the Scrutinize campaign, which chose to prioritize information over emotion (4).
In a study comparing the effects of an emotional public service announcement about child abuse to those of a public service announcement making a rational appeal about child abuse, Bagozzi and Moore (1994) found that the emotional appeal invoked a greater helping response than a rational appeal. Similar effects were observed when comparing a public service announcement with a strong emotional appeal to one with a weak emotional appeal. The authors conclude that advertisements invoking strong emotions are more successful in influencing attitude formation and decision making (5).

Critique II: Scrutinize Treats Sexual Behavior Like a Planned Behavior

The Scrutinize campaign is based largely on the Health Belief Model. The creators of the Health Belief Model theorize that perceived susceptibility to disease and severity of the disease, along with perceived benefits and perceived barriers, influence an individual’s intention to perform a behavior (6). The main strategy of the Scrutinize campaign is to increase perceived susceptibility to HIV infection. This is exemplified by the HIV Ninja’s relentless pursuit of the animated human characters. When HIV is transmitted, it is depicted as spreading rapidly from one person to the next and throughout entire sexual networks.
The Health Belief Model posits that behavior is preceded by an intention that is formed by a rational weighing of factors in the model (6). By educating the target audience that they are more susceptible to HIV infection if they engage in unprotected sex, sex with multiple concurrent partners, and cross-generational partners, the creators of the Scrutinize campaign are attempting to affect this weighing of factors that occurs in the Health Belief Model. This strategy is premised on the notion that young adults in South Africa inadequately perceive that they are susceptible to HIV infection. It is worth noting that 18% of South Africans (15-49 years) are living with HIV (7). It is certainly important for the target audience to be aware of their susceptibility to HIV infection but this is not the most effective approach to behavior change communication in this setting.
Behaviors can be both unplanned and irrational. Larabie (2005) found that the majority of quit attempts by smokers are unplanned (8). Hicks (2001) describes that in the development stage of the Truth anti-smoking campaign in Florida, formative research showed that among youth, “there was 100% awareness that tobacco killed” yet smoking was prevalent in this population (9). Young smokers reported they understood the long-term health effects of smoking and had personal experience watching loved ones suffer from diseases caused by smoking (9). Similarly, young adults in South Africa presumably do not lack the knowledge that they are highly susceptible to HIV infection if they engage in unsafe sexual behaviors, yet the behaviors persist.
In the context of sexual behaviors, the fundamental flaw of the Health Belief Model is the tenet that sexual behavior is the result of a predetermined intention. In the Risk-As-Feelings Framework, Lowenstein et al. (2001) argue that behaviors often occur without a predetermined intention, particularly when strong emotions and feelings are present. The Framework proposes a central role for the immediate visceral feelings at the time of behavior (10).
Ariely (2008) explores sexual decision-making in a state of sexual arousal. While in an unaroused “cold” state, young male subjects were asked to answer questions while imagining oneself were sexually aroused. Subjects were later asked the same questions in a state of sexual arousal. While sexually aroused, men were considerably less likely to state that they would use a condom in various circumstance than they were when in an unaroused state. Ariely states that our “irrational self comes alive in an emotional place” (11). As Victor Scrutinize instructs the campaign’s audience to “wear a condom every time,” any plans to do so may become irrelevant when it matters most.

Critique III: Scrutinize Ignores Structural Factors

The creators of the Scrutinize campaign fail to address in any of the advertisements the structural factors that underlie risky sexual behavior among their target audience. Examining three of these advertisements with a common theme illustrates why this is very flawed approach.
Three of the Scrutinize campaign advertisements directly address the “sugar daddy” and “sugar mama” phenomena, characterized by young people engaging in sexual relationships with considerably older people who provide them with money and other gifts. One such advertisement warns of a “sugar surprise” in the form of HIV transmission. The audience is told, “Don’t get more than you bargained for from sugars.” The advertisement also warns that after acquiring HIV from an older partner, HIV can then be transmitted to a partner in one’s age group with whom one is in a concurrent, more emotionally committed relationship. In the other two cross-generational-themed advertisements, a sugar daddy is depicted as an unattractive wealthy man with odd mannerisms who aggressively pursues several attractive young women. The young women quickly make the correct decision to reject his advances (2).

The Scrutinize campaign’s focus on the health risks that occur in transactional relationships is an example of what Link and Phelan (1995) identify as a disproportionate focus on risk factors that are “relatively proximate causes of disease.” The consequence of this disproportionate focus on proximate causes is neglect of the social factors that bring about these more proximate risk factors (12). There are certainly reasons why teens and young adults engage in transactional relationships with much older partners. For example, poor youth or young adults may engage in transactional relationships in order to gain needed money and gifts (13).
The focus on proximate risk factors is appealing to the belief systems of Western culture (12). This belief structure holds that because the risk factor is “potentially controllable at the individual level,” the proximate cause is therefore changeable (12). Undoubtedly, bargaining power and the ability to negotiate safe sex are essential to safe sexual behavior (14). The power differential that makes cross-generational sex more dangerous is same power differential that may make cross-generational relationships difficult to end. Merely instructing young people not engage in transactional, cross-generation sex is most likely not enough to decrease the prevalence of the practice.
Maslow’s proposed Hierarchy of Needs is also instructive in this context. Maslow states, “a person who is lacking food, safety, love, and esteem would most probably hunger for food more strongly than anything else.” Citing another low order need, safety, Maslow states that person chronically lacking safety may be characterized as living for safety alone (15). Considering cross-generational transactional sex or any risky sexual behavior engaged in by young South Africans, one can understand that long-term health may not be considered a top priority if lower order needs are not met.

This need for resources can be considered a fundamental cause of disease. Attempts to eliminate the effects of the fundamental cause without eliminating the fundamental cause enables the effects to continually reemerge (12). The Scutinize campaign does not attempt to eliminate, nor does it even acknowledge, the structural factors which bring about unsafe sexual behaviors. Scrutinize is thus a perfect example of what Link and Phelan, describe as an ineffective effort to eliminate an exposure “without a clear understanding of the context that leads to exposure” (12).

Proposed Intervention

An intervention that would effectively reduce the rates of transmission of HIV among young adults in South Africa would take a much different approach than the Scrutinize campaign. Like the Scrutinize campaign, the proposed campaign, Latitude, will be rooted in mass media promotion with supporting activities and will aim to reduce the rates of transmission of HIV among young South Africans. Rather than targeting 18-32 year olds, Latitude will target a younger audience of 14-24 year-olds. This shift will enable the campaign to reach youth who are beginning sexual activity and are at an age at which their outlook on life is developing most.
The mass media component of the Latitude campaign will portray the daily lives of two fictional South African 17 year-olds, a male and a female. The campaign will develop their characters separately, not implying any interaction between them, with each advertisement focusing on only one character. They will be from two different socioeconomic backgrounds and their surroundings will be designed to be familiar to the target audience. The promises of the advertisements will be freedom, control, and acceptance. The word latitude will be used to convey the freedom and independence depicted in the advertisements. For example, an advertisement depicting a character excelling at sports and experiencing camaraderie with teammates will fade to a screen reading “Latitude to compete.” An advertisement depicting simple pleasures of being with one’s family will fade to a screen that reads “Latitude to be at peace.” Some of the ads will depict the characters making healthy relationship decisions. The text of the slogans will be accompanied by an image of a globe, taking advantage of the dual meaning of the word latitude as both a synonym of freedom and geographic placemarker of sorts. The globe will symbolize thinking beyond the current constraints on one’s life.
The second component will be a peer outreach program that will encourage youth and young adults to become committed to the campaign and its associated aspirational promises. The campaign organizers will get buy-in from school administrators. Teachers will turn over class time to peer educators to discuss with their fellow students what latitude means to them, without input from the teacher. Students will create a Latitude “map” of personal aspirations. These sessions will culminate in the optional signing of a pledge to “know my latitude.” Social media and merchandise will be used to reinforce this sense of commitment.
A third and final component of the campaign will be Latitude-branded drop-in centers staffed by people who will ensure a safe and supportive environment for youth and young adults. These drop-in centers will also provide young people in need an opportunity to apply for grants from a modest “Latitude fund.” The Latitude fund will provide small grants for basic needs such as school fees and bus passes for poor children in the community. All three components will make the strongest of efforts to avoid stigmatizing those living with HIV.

Support I: Latitude Engages the Audience on an Emotional Level

The Latitude campaign makes a promise of freedom, control, and acceptance with strong support in the depicted scenes. The continual storylines focusing on only two main characters will make the audience emotionally committed to the well-being of the characters.
This strategy is in line with Kotler and Zaltman’s assertion that social campaigns resembling for-profit product campaigns are more likely to be effective at producing the desired behavior than social campaigns that ignore advertising principles established in the for-profit sector (3). Hicks states, in reference to the Florida Truth campaign, “if we wanted youth to really embrace our anti-tobacco effort, it made sense that we should deliver it just like other successful US youth products, such as Adidas, Fubu, or Abercrombie – in a branded form they understood” (9). The intention is to increase the motivation or “force” toward the goal portrayed in advertisements. Freedom, control, and acceptance are already universally appealing (3). The Latitude will increase the viewers’ motivation to attain them.
An important component of the Latitude advertisements is the creation of characters who are similar to the target audience. The actors will look like the target audience, engage in the same activities, be portrayed in similar surroundings, and will be authentic and realistic. Importantly, they will not verbally instruct the audience to behave in a certain way. Instead, they will lead by example, portraying social proof that it is possible to be committed to attaining the promises of the campaign. By doing so, they are not posing a threat to the attitudinal freedom of the audience (16). These are the same reasons why peer educators are used in the second component rather than adults.
The core concept behind the choice of portraying the characters as very similarity to the audience, in very similar surroundings is psychological reactance theory. Because the advertisements will invoke positive emotions rather than the negative emotions that stem from threats and fear, reactance will be limited or nonexistent. Silvia (2005) found that threats can cause a boomerang effect, bringing about the opposite behavior from that which was intended. However, this phenomenon was only observed when the communicator’s similarity to the audience was unknown or low. The key difference between a response to a similar communicator and a response to dissimilar communicator is the concept of liking. Communicators that are similar to the audience and liked by the audience are much more able to effectively promote change than communicators who are not (16).

Support II: Latitude Creates a Sense of Commitment to Evoke Feelings at the Time of Decision-Making

Inevitably, decisions regarding sex will be largely driven by feelings at the time of decision-making rather than the rational weighing of factors proposed by the Health Belief Model. A solution to this challenge is to impact the feelings experienced at the time of decision-making (10).
Latitude’s “know my latitude” pledge, social media activities, and merchandise will results in a sense of commitment. When feelings are pushing an individual toward risky behavior, such as sex without a condom, the negative feelings associated with breaking the pledge will weigh on the decision. Describing the development of the Truth campaign, Hicks states, “In a search to define one’s identity, brands (like piercing, haircuts, and even tobacco use) serve as a shorthand way for youth to identify themselves to the world” (9). In that way, signing the pledge and wearing the merchandise makes loyalty to the Latitude brand a part of one’s identity. This part of their identity will include their desire to achieve the promises of the Latitude campaign: freedom, control, and acceptance. As the beneficial decisions portrayed in the Latitude advertisements becomes part of one’s identity, a stronger desire to make beneficial decisions will emerge.
Giné,et al. (2010) found a voluntary commitment product can be an effective way to help smokers quit smoking. The Committed Action to Reduce and End Smoking (CARES) program allows smokers to deposit any amount of money which will be forfeited if they fail urine tests that identify cigarette byproducts within six months of signing the commitment contract. An analysis free of major causes of selection bias that considered outcomes among all smokers offered to participate in CARES, found that those offered were 3.3% to 5.8% more likely to pass a urine test after six months. Even after 12 months, when the financial incentive was removed, the non-smoking behavior largely persisted (17).

Support III: Latitude Addresses Structural Factors

The Latitude campaign attempts to mitigate some of the structural social factors that bring about risky sexual behaviors. Addressing the structural factors that bring about more proximate causes of HIV infection is a very difficult task. Considering the deep social distress found in any society and issues of poverty and violence that plague some South African cities, no campaign can solve all social troubles. However, the Latitude campaign aims to make a meaningful change for a small number of children and young adults who benefit from its drop-in centers and Latitude fund. It is intended that helping a modest number of children will have modest ripple effects throughout the society as people connected to the recipients of aid will benefit indirectly.
Link and Phelan describe how proximate risk factors for disease often have a more fundamental cause (12). The three fundamental structural causes addressed by the Latitude campaign are poverty, safety, and a need for guidance from caring adults. Maslow proposed in the Hierarchy of needs that higher order needs, such as long term health will not be acted on until lower order needs are met (15).
According to Blankenship, “structural interventions locate the source of public health problems in factors in the social, economic, and political environments that shape and constrain individual, community, and social health outcomes. In Blankenship’s framework for classifying structural interventions, the structural component of the Latitude campaign is an “accessibility” intervention. Accessibility interventions “explicitly acknowledge that health is a function of social, economic, and political power, and, as such, manipulate power and resources to promote public health. Such an intervention differs from an “availability” intervention which instead focuses on the behaviors and tools necessary to prevent individuals from experiencing a negative health outcome (18).


The Latitude campaign aims to succeed in areas where the Scrutinize campaign fell short. By properly using advertising theory to evoke emotions, treating sexual behaviors as largely unplanned and subject to irrational feelings, and addressing some structural factors that underlie sexual risk-taking among South African youth, the Latitude campaign has great promise to slow the spread of HIV.


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