INTRODUCTION

Brothers for Life

BackgroundBrothers for Life launched in South Africa in 2009 to promote the health and wellbeing of South African men, with a specific focus on HIV prevention, Voluntary Medical Male Circumcision (VMMC) and Sexual and Gender Based Violence (SGBV).

Brothers for Life is funded by the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the United States Agency for International Development (USAID), and is implemented as a partnership between the Centre for Communication Impact (CCI, previously JHHESA), the SANAC Men’s Sector, the Department of Health, and USAID/PEPFAR. In addition, over 40 civil society partners have participated in the program.

Why we chose Brothers for Life • It it is a long running program (2009 – present) that addresses several social issues, giving us an opportunity to evaluate program consistency

and continuity over time, while also enabling us to evaluate a specific marketing campaign. For the purpose of this case study, we chose to focus on the TestaBoy HCT (HIV Counseling and Testing) campaign because it had been evaluated for behavioral impact.

• The implementing organizations put considerable effort into documenting the program, providing us with background information, evaluation reports, etc., to develop our case study.

• Brothers for Life expands the scope of our case studies, enabling us to assess a social movement brand in addition to the SBCC, edutainment, and social marketing brands and campaigns that make up our case study series.

Findings• B4L is a solid example of an umbrella brand that is clear and relevant to the audience and has been supported consistently over a 10-year

period. The overall vision of B4L – to redefine masculinity and male social norms – is clearly understood by all stakeholders, is relevant to the target audience, and was executed through a brand identity that has been consistently applied throughout the project’s lifetime.

• Benefit clarity, relevancy, and believability are critical to program success. While there were many positive attributes associated with the TestaBoy campaign (mind and heart opening, use of communication vehicles and channels) the TV ad was confusing, detracting from the main benefit communicated in the campaign – that whether you test positive or negative, you are still the same person.

• It is challenging to achieve several behavioral objectives in a short timeframe: The TestaBoy HTC campaign that we evaluated as part of this case study had some positive results on the stated program objectives. However, given the short duration of the campaign (six months) and number of campaign objectives (5 objectives, measured by 7 indicators), it may be that the campaign was too ambitious. For example, the campaign included 9 different documentary style videos, each developed to address a specific fear about testing or knowledge gap about HIV. Had the campaign limited the number of objectives and focused the communication on addressing one or two fears directly tired to program objectives, they may have had stronger message consistency. Alternatively, had the videos been aired over a longer period of time, on social media, TV, commuter TV, etc., the messages may have had greater impact.

BROTHERS FOR LIFE GOOD

1. IDENTIFY THE AUDIENCE AND BEHAVIOR CHANGE OBJECTIVE

Based on epidemiological data of HIV prevalence and patterns, national health surveys, and quantitative and qualitative research, the team identified a primary audience (men 18-34) and secondary / influencer audience (women, older men, decision-makers, religious, community, and business leaders, etc.). Data indicated that HIV prevalence among men increased sharply after age 30 (25.6% prevalence among men ages 30-34); that men were less likely than women to get tested for HIV; and that when they did test HIV+, they were less likely to seek timely treatment and care. The overall behavior change objective is to inspire men to take personal responsibility for their health and wellbeing, with specific campaigns developed to tackle specific behavioral change objectives related to Brothers for Life’s focus areas of HIV/AIDS, SGBV, and MMC. The table below summarizes specific behavior change objectives based on a sample of the Brothers for Life campaigns over the past 10 years. We also note that each campaign identified a more specific audience. For example, the primary audience for the HCT campaign evaluated in this case study was “young, virile men in the prime of their lives” who are likely unemployed and also likely to engage in high risk sexual behavior.2 Given the breadth of the audience (men 18-34, women, older men, decision-makers, etc.), we scored this best practice as “good.”

1https://www.brothersforlife.org/downloads.html, 2Counselling and Testing, Presentation to Brothers for Life, Joe Public, Sept 2015

Primary Audience South African Men, All Ethnicities, Age 18-34, low to middle income, in 27 priority districts Attained middle school education

Campaign/ Issue1

Manifesto Brand Launch (2009-2011; updated in 2013)

“Game of Life” HIV and SGBV (2009-2011)

PMTCT “Brothers for Mothers” (2009-2011)

SGBV (2009-2011); Anti-rape (2017)

HCT (2016) MMC (2017)

Behavior Change Objectives

Be the “new” man in South Africa: Take personal responsibility for your health, treat women with respect, protect your family

Do the right thing• Always wear a

condom• Avoid unprotected

sex, even when drinking

• Know your HIV status

• Oppose violence against women

• Choose a single partner over multiple chances w HIV

Support your partner in pregnancy, including taking steps to avoid HIV transmission

Oppose GBV, including how to support women who may be victims and men who may commit GBV

Choose not to commit rape

Get tested for HIV; use condoms to maintain negative status or seek treatment if positive

Get medical circumcision

EXCELLENT BROTHERS FOR LIFE

2. UNDERSTAND THE AUDIENCE

Audience understanding was grounded in local knowledge (the design and implementation of B4L was driven by resident South Africans, including CCI staff, the media agency, and most partners). This knowledge was complemented by existing national studies (National Communication Survey, the Human Sciences Research Council HIV/AIDS Survey, etc.); community-based surveys; and extensive consultations with national and provincial government personnel, community leaders, and South African men; These findings suggested that men felt that they had been left out of the HIV prevention discussion and/or treated as perpetrators. With each initiative, the team conducted additional research (e.g., focus group discussions among men drawn from community outreach groups) to better understand knowledge, attitudes, practices, and experiences relative to the behavior in question (e.g., HIV Counseling and Testing (HCT)).

Highlights from HCT Foundational Research1

Often men with high risk profiles do not perceive themselves to be at risk; familiar partners are safe because they are known, regardless of whether their HIV status is known.

Many also suspect that they are HIV positive but avoid testing; not knowing is preferable to knowing. “Going to get tested is the confirmation of an unspoken truth.”

There is also a belief that knowledge brings death, but ignorance means you are going to live. Once you know your (positive) status, something changes in your head; others will notice, or you will start to make yourself sick, either from worry or because “consciousness” will trigger symptoms.

Those who have friends or family members living with HIV seem to have less fear of testing; having known someone who has coped seems to demystify the disease.

Social norms that suggest that men are not supposed to get sick also keep men from health clinics.

1“’Confirmation of an Unspoken Truth:’ Community Perspectives on HIV Testing Behavior,” USAID, CCI, and Joe Public, Nov 2015

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3. ARTICULATE AN INSIGHT

The overall insight behind B4L – that beliefs about masculinity and strength prevented men from taking responsibility for their own health and wellbeing and that of their families – is strong. There is tension within the various social norms about masculinity – multiple partners and unprotected sex on one hand, and taking responsibility for the family on the other hand. It is also true, but only obvious once it is pointed out. It is emotional: those who had been exposed to Brothers for Life indicated that it tapped into something that many South African men and women had felt: that men had been left out of the dialogue about HIV and were portrayed as the perpetrators. And finally, it can inspire the audience to think or feel differently because it challenges social norms about masculinity.

INSIGHT:

Men’s (and society’s) beliefs about male social norms – multiple partners, unprotected sex, showing strength through physical force, never appearing weak – prevent men from taking responsibility for their health and the health and wellbeing of their family.

BAM360 team criteria for an audience insightIt has tension It is true but not

obvious It strikes an emotional

chord

It inspires the audience to think or feel differently

Yes Yes Yes Yes

EXCELLENT

BROTHERS FOR LIFE EXCELLENT

4. DEFINE THE BRAND VISION – CLARITY & RELEVANCE

1) Collinge, J. et al. Talking Man to Man: The Story of Brothers for Life. Johns Hopkins Health and Education in South Africa. South Africa. 2013; 2) Center for AIDS Development, Researchand Evaluation 2011. Transcripts of focus groups with outreach workers from Lesedi Lechabile, Mothusipilo, The Valley Trust and JHHESA partners in the Western Cape. Unpublished.

Brothers for Life is a social and well-being movement aimed at mobilizing men to take responsibility for their own health. This brand Manifesto, originally used to launch the brand in 2009 and revised in 2013, brings this to life for the audience. As one community member said, “Brothers for Life gives men their belonging, they think it belongs to them, they know now that they belong somewhere.1” A qualitative review conducted in 2011 among participants of community activities indicated that this vision was clear and that it resonated with the target audience. It sought to create a sense of community among men, giving them a way to participate in a positive message2.

Brothers for Life is a social and well-being movement aimed at mobilizing men to take responsibility for their own health.

BROTHERS FOR LIFE GOOD

5. DEVELOP THE BRAND IDENTITY

We scored the brand identity as “good” – it suggests masculine strength and men supporting men and has been executed consistently for 10 years. We see opportunities to be more distinctive and potentially evolve the slogan, “Do the right thing” which may border on finger wagging.

Distinctive: Brothers for Life is distinctive relative to other HIV/ public health campaigns, but less so when compared with commercial brands that target men.

Has a Personality: The Brothers for Life personality is optimistic, inspiring, approachable, and supportive.

Reflects brand vision: The identity supports the brand vision in that it suggests masculine strength and men supporting men, but there are also elements that border on finger wagging. For example, men commented that the slogan (Do the right thing!) “is something your mother told your all your life.”1

Executed consistently: The brand identity has been executed consistently over a 10-year period. Most mass media, social media and live community events use real men and / or couples to emphasize the brotherhood of men and the notion that there is an existing community of men who already live B4L’s values.

1) J. Collinge et al. Talking Man to Man: The Story of Brothers for Life. Johns Hopkins Health and Education in South Africa. South Africa. 2013

Brothers 4 Life Manifesto Video

BROTHERS FOR LIFE GOOD

6. COMMUNICATE A BENEFIT

HCT Campaign – TestaBoy: The campaign included a TV ad and 9 documentary style videos featuring real people (brand ambassadors). The benefit communicated in both the TV ad and the documentary videos – you are still the same person whether you test positive or negative for HIV – resonates with the audience. It was communicated well in the documentary videos, but was not clear in the TV ad. In fact, while the audience understood that the ad was about getting tested for HIV, they found it confusing and did not take away the main message “positive or negative, you are still the same person.” The table below summarizes audience feedback to the TV copy, which was the campaign vehicle that drove the most exposure. Based on the audience feedback to the TV copy, we scored this best practice as “good.” We also note that a benefit typically offers something to the audience. In this case, ‘you are the same’ addresses a fear, but does not offer anything to the audience.

Audience feedback on the TestaBoy campaign TV ad Clarity Believability Resonance

(among those who understood the ad)

“It is a bit complicated. The message is not clear enough. When we interpret what is actually happening… What is the relevance of changing clothes and stuff like that?”

“The guys that move things around are the reason I’m so confused.”

Some focus group participants commented that the ad was not realistic; “I don’t think it’s realistic… I’ve never seen it. There’s no ways you can find out your HIV status and on the same day, tell all your friends and have them support you all at once…”

“I think I liked the concept of the whole advert because it shows and encourages us to go get tested, because things won’t change the way we think they’ll change.”

“… you’re just thinking in your head that things maybe will change if you, maybe why should I go test. So basically it did talk to me… yes, there’s like a whole lot of mental war happening.”

GOOD EXCELLENT AVERAGE/POOR

Evaluation of the Impact of the Testa Boy HIV counselling and testing Campaign among Men and Women in South Africa. USAID, Genesis, Center for Communication Impact. Final Report, October, 2017

BROTHERS FOR LIFE GOOD

7. TOUCH THE HEART, OPEN THE MIND

HCT Campaign – TestaBoy: The ambassador videos, which featured real people and were developed to address fears and information gaps about HIV testing and HIV/AIDS, were heart and mind opening, as evidenced by the audience comments to the ambassador videos and related social media posts on Facebook. For example, the two videos that received the highest levels of engagement, Sisimo Msomi (the story of a 25-year-old man living with HIV) and Oziel and Mpumi (the story of an HIV discordant couple), received positive feedback thanking the ambassadors for sharing their stories and acknowledging them as inspirational, “this is wonderful – you guys are shinning bright lights to those in the dark1” [male participant]. The videos and related social media content also generated audience questions, suggesting they inspired the audience to learn more and think differently, for example, “I also nid an advice, Im wanna go n check my HIV status, but I’m scared coz I know I’ve done some wrong things before2” [male participant]. The Brothers for Life moderator responded to this and other questions with empathy and information.

While the ambassador content was strong, we scored this best practice as “good” because the high level of confusion in the TV spots (discussed in the “benefit” best practice section) distracted from the mind and heart opening potential of the message “positive or negative, you are the same person.”

1) Clarfelt, A., et al, “Brothers for LIFE HIV Counselling and Testing campaign: An evaluation of the social media campaign on Facebook,” 2) Ibid.

PLAYPLAY

BROTHERS FOR LIFE GOOD

8. SELECT THE RIGHT MARKETING VEHICLES AND ENSURE MESSAGE CONTINUITY

HCT Campaign – TestaBoy: The TV spot and ambassador videos came to life through marketing vehicles that closely reflected the target audience’s media consumption habits, as indicated in the graph below. At an overall brand level, Brothers for Life has consistently communicated the overall message of taking responsibility for one’s health for a period of ten years. However, we scored this best practice as “good” given the relatively short duration of the campaign (campaign elements ran from June – Dec 2016) and opportunity to leverage Whatsapp to better align with audience media habits.

M. Fineberg, et al, Evaluation of the Impact of the Testa Boy HIV Counseling and Testing Campaign among men and women in South Africa. Genesis Analytica.

The percentage of respondents using different media channels ‘often,’ ‘seldom’ and ‘never’ weighted sample

BROTHERS FOR LIFE GOOD

9. DELIGHT THE AUDIENCE

Brothers for Life - Overall Brand: While there were campaign elements that were likely considered to be ‘delightful’ (the use of popular sports figures, branded back packs, caps, t-shirts distributed at company events, etc.), the project team placed greater emphasis on audience engagement vs. audience delight. For example, the audience was clearly moved by the campaign, describing it as “powerful” and engaging with the content, but the brand does not necessarily “delight” the audience. It is likely that ways to delight the audience (for example, launching a program to celebrate men on Father’s Day), may be challenging to fund and execute without an obvious direct link to health outcomes.

Use of popular sports figures in ads and as ‘ambassadors’ during World Cup was very popular among men

Branded swag giveaways to community members and mobilizer teams for being a part of the B4L movement

BROTHERS FOR LIFE GOOD

10. INSPIRE AUDIENCE ENGAGEMENT

HCT Campaign – TestaBoy: The campaign had good engagement via Facebook and inspired a significant percentage of the audience to speak with others about the importance of HIV testing. Approximately 200,000 people engaged with the campaign via Facebook, out of a total reach of 1.5M. As documented in an evaluation of the FB campaign, “the fact that many participants requested information and services through the Brothers for Life campaign, whether asking a question about a particular health issue, wanting to find out about services in their local area, or requesting to join the Brothers for Life campaign, is indicative of a high level of participation and engagement with the campaign1.”

Social Media Content EngagementWith 180K likes, the B4L Facebook page has a strong following, suggesting interest in the brand. The TestaBoy HCT delivered strong engagement, driven by views and reactions to two ambassador videos (engagement was strong among women vs. men). Based on the campaign’s final evaluation, 2.3M people viewed the Sisimo Misimo video (includes social media, website, TV, etc.).

TestaBoy inspired the audience to engage with others

1) Clarfelt, A., et al, “Brothers for Life HIV Counselling and Testing campaign: An evaluation of the social media campaign on Facebook. CADRE, 2017.

BROTHERS FOR LIFE

11. TEST MESSAGE EFFECTIVENESS

B4L measured TestaBoy’s marketing quality through two primary studies. The first was an assessment of the overall concept and message quality across all channels; the second was a specific evaluation of TestaBoy messaging on Facebook. Both studies were conducted by Cadre, B4L’s research partner. While B4L employed a validated approach to assessing marketing quality, both studies were conducted after TestaBoy was launched; we did not find evidence of TestaBoy copy testing prior to launch; however, there is evidence of pre-launch testing of other Brothers for Life campaigns. We scored this best practice as “average”; the issues around clarity and confusion in the TV copy should have been identified and addressed.

AVERAGE

TestaBoy TV Ad1

In 2017, a total of 40 men and 29 women participated in a qualitative evaluation of the entire TestaBoy Campaign. Participants were asked to assess billboards, radio and TV. The findings in this evaluation were mixed, with many respondents commenting that the centerpiece TV spots were confusing.

Viewers didn’t understand the purpose of the two spots and found the messages between the two unclear. Viewers also thought the spots emphasized the wrong fear. Instead of focusing on men’s fears of how their lives would change if they tested positive for HIV, respondents felt the creative focused more on fear of the test itself. Viewers also thought the purpose of the ‘change agents’ used in the TV spots was unclear, and some thought they were actually reinforcing stigma.

Finally, some expressed concerns about the overall tone of the campaign, indicating it was too serious and would only reinforce men’s fear.

Social Media Campaign – Brand Ambassador Videos2

The qualitative social media study was designed to serve several objectives including informing B4L’s ongoing use of social media for all its campaigns, and an evaluation of whether and how the target audience engaged with the brand using social media after being exposed to TestaBoy messages and content.

While B4L had used Facebook for a number of campaigns, the evaluation focused primarily on the quality of the TestaBoy campaign content, including the 9 documentary-style videos. As a measure of message understanding and acceptability, the study measured the level of engagement with the page -- including likes, shares and dialogue generated by exposure -- and compared levels of engagement across the 9 videos. Findings indicated that the first two videos had the highest levels of engagement. Respondents were supportive of the content, “We need video clips like this in social networks…not the nonsense we see daily. Bigup Brothers for Life Yenzakahle.” Male follower.

1) Hajiyiannis, H. and Orr, NM, “Post-broadcast evaluation of the Brothers for Life national HIV Counselling and Testing mass media and out of home campaign, CADRE, 2017; 2) Clarfelt, A., and Hajiyiannis, H., “Brothers for Life HIV Counselling and Testing campaign: An Evaluation of the social media campaign on Facebook, CADRE, 2017.

BROTHERS FOR LIFE GOOD

12. EVALUATE PROGRAM RESULTS

HCT Campaign – TestaBoy: At the end of the campaign, which ran for 9 months from June 2017 to March 2018, a research organization was hired to conduct a cross sectional study among 3,000 South African men and women. Those who had medium exposure or high exposure to the TestaBoy campaign were more likely to agree with ideational factors for HIV testing, including attitudes and perceptions, self-efficacy, and social norms. We scored this best practice as “good”, as the team was able to show some results against the defined program objectives. However, the cross-sectional nature of the survey and self-reported exposure make it difficult to draw concrete conclusions. We also suspect that there are too many objectives – and the campaign duration was too short – to make a significant impact across a greater number of campaign objectives.

Evaluation of the Impact of the TestaBoy HIV Counselling and Testing Campaign among men and women in South Africa

Indicators ResultsIncrease the % of men and women who regard men testing for HIV as strong and responsible men

Those who were exposed were 1.5x more likely to agree vs. those who were not exposed

Decrease the % of men and women who report that men do not test for HIV because they are scared it would change their lifestyle No significant impact

Increase in the number of friends that men and women report who have tested for HIV No significant impact

Decrease the % of men and women who report that men in their community are scared to test for HIV because they think that if they test HIV positive, they can never have a relationship again.

No significant impact

Decrease the % of people who report that men in their community are scared to test for HIV because their family and friends will reject them.

Those who were exposed were 20% less likely to agree vs. those who were not exposed

Increase the % of men who report having tested in the past 12 months for HIV Those who were exposed were 1.4x more likely to have tested in the past 12 months

Increase the % of people who report that men in their community who test positive feel free to disclose their HIV status to friends and family No significant impact

BROTHERS FOR LIFE GOOD

13. MEASURE BRAND PERFORMANCE

As part of the TestaBoy campaign evaluation, the team measured brand awareness, including recognition of the logo, association of the logo with Brothers for Life, and understanding of what Brothers for Life means. We scored this best practice as “good”: brand awareness and understanding were measured and well understood; there may be an opportunity to better track other brand-related measures, such as resonance, trust, etc.

Source: Cadre, 2017

BROTHERS FOR LIFE GOOD

14. EVALUATE MARKETING VEHICLE EFFECTIVENESS

The final evaluation report included measurement of campaign exposure, using TV / online, billboard and poster, and radio as the primary vehicles. The team did a separate, detailed evaluation of Facebook, to assess the level of engagement, types of conversations, and the degree to which videos shown on Facebook and the resulting conversations changed behavior. However, in the final evaluation, it would be helpful to to tease apart the effectiveness of the various TV channels (commuter TV vs. regular TV) and the Facebook campaign compared to each other, which may have been more effective than radio or TV.

M. Fineberg, et al. Post-Broadcast Evaluation of Brothers for Live HIV Counseling and Testing mass media and Out of Home Campaign, 2017. Genesis Analytica.

BROTHERS FOR LIFE

15. ORGANIZATIONAL STRUCTURE // 16. PROCESS & DECISION-MAKING // 17. PEOPLE & CAPACITY // 18. REWARDS & INCENTIVES

ELEMENT DESCRIPTION

Organizational Structure Brand and communication responsibilities are split among multiple implementing organizations. Initially, communication funding was concentrated with one implementer. This shifted in 2014, with PEPFAR dividing funds for communication between multiple agencies: the former JHHESA (recently spun off to locally registered Center for Communication Impact) manages strategic communications such as the creatives, media, etc.; another organization manages community-level work; and the DoH manages the helpline and public services. As a result, B4L involvement with the helpline and community agents was limited to one training and provision of some B4L materials.

Process & Decision-making Many decisions related to resources and priorities are made by the donor, PEPFAR, which has shifted priorities from demand side behavior change to delivery of clinical services and treatment This shift in priorities has resulted in limited motivation to invest in long term marketing efforts or brand building. There may be an opportunity to bring more marketing and communication expertise to decision-making. For example, the implementing organization has brought forward a number of ideas to drive brand passion and engagement; however, ideas that are designed to build the brand, but are not directly related to a health outcome, have not been supported. CCI did lead partner meetings among the implementing partners but the extent to which these meetings deepened understanding of the B4L brand is unknown.

People & Capacity Over the years, decreasing interest in behavior change among donors has limited opportunities and budgets for capacity building. On the other hand, local creative agencies operating in South Africa are highly skilled, and B4L has worked with the same agency for the entire life of the brand. In terms of “employee engagement with the brand,” the extent to which external partners were trained on B4L is not clear. B4L did evaluate the extent to which the training enabled staff and partners to do their job but there is no evidence of any evaluation of employee (implementing staff or partner) engagement with the brand itself.

Rewards & Incentives There are multiple men’s health brands. At one point, the DoH introduced an umbrella men’s brand but did not sustain it. More recently, in partnership with the DoH, the CDC has created the Man Up brand to promote MMC and condom use after circumcision. There may be an opportunity to consolidate and strengthen existing programs.