Taxi Drivers, Hiv and Edutainment in South Africa

Taxi Drivers, Hiv and Edutainment in South Africa

1

TAXI DRIVERS, HIV AND EDUTAINMENT IN SOUTH AFRICA

Title page

Jiving and driving: Taxi drivers, HIV and edutainment in rural South Africa

Astrid Jane Treffry-Goatley

Postdoctoral student, Centre for Visual Methodologies for Social Change (CVMSC), School of Education, University of KwaZulu-Natal, South Africa

Africa Health Research Institute, South Africa

Abstract

The HIV epidemic in South Africa has had a major impact on the national workforce, in particular on unskilled workers, such as minibus taxi drivers who play a key role in the public transportation system. Drivers remain at an elevated risk of HIV infection due to their social dislocation, the risky environment in which they operate and prevailing gender norms. Yet, although there is a dire need for targeted health interventions the unregulated nature of the taxi industry and the long working hours of the drivers present a significant challenge. Here, we describe an innovative low-budget public engagement project where used edutainment, popular music and small media to engage minibus taxi drivers and their patrons in a rural South African community of high HIV-prevalence. We produced a series of three edutainment CDs over two years and freely distributed over 1000 copies of these to local taxi drivers. We used a small-scale quantitative survey to test the reach of the intervention, and its influence on HIV-related knowledge and behaviours. Results suggested that approximately half driver respondents and one-third of taxi users respondents reported exposure. Although there was no significant association between exposure and knowledge or reported behaviour p=0.335, we found a strong association between exposure and dialogue about HIV in taxis p<0.000. We suggest that this study be followed by a sequential explanatory study in a mixed-methods design to further explore the link between the CDs and dialogue stimulation in taxis and to better understand the nature of this dialogue.

Jiving and driving: Taxi drivers, HIV and edutainment in rural South Africa

Introduction

HIV remains a key health concern in South Africa. The epidemic has had a major impact on the country’s workforce, in particular on unskilled workers, who are significantly more likely to be infected with HIV than highly skilled or skilled workers (Evian, Fox, MacLeod, Slotow, & Rosen, 2004). Semi-skilled and unskilled workers are the key drivers of the national economy and the fiscal impact of their illness cannot be underestimated. Internationally, taxi drivers are a population group that remains highly vulnerable to sexually transmitted diseases (Lakew & Tamene, 2014; Ncama et al., 2013; Orisatoki & Oguntibeju, 2010; Siulapwa, 2012). Minibus taxis are the primary mode of public transportation and move approximately 60% of the population on a regular basis (Ncama et al., 2013). However, research has shown that similar to other ‘highly-mobile’ individuals, minibus South African taxi drivers are at an elevated risk of HIV infection due to their social dislocation, the risky environment in which they operate and poverty (Mchunu et al., 2012; Tanser, Bärnighausen, Cooke, & Newell, 2009). Yet, despite the recognised vulnerability of drivers, since the industry remains largely unregulated by the state, drivers remain a difficult population group to reach and there is a great shortage of targeted health interventions (Mchunu et al., 2012).

The large majority of drivers in South Africa are men and it would seem that prevailing gender norms pose an additional risk to the health of this population group for it is well documented internationally, that much fewer men visit healthcare facilities than women do (Ncama et al., 2013; Peacock, Weston, Evans, Daub, & Grieg, 2008). These patriarchal norms have had a major impact on male health in Africa, and while there is an almost equal number of men and women infected with HIV in Africa, more men die while on ART (Cornell, McIntyre, & Myer, 2011, Taylor-Smith, Tweya, Harries, Schoutene, & Jahn, 2010), men also initiate ART with more advanced HIV disease (Cornell et al., 2009, Stringer et. al., 2006) and they are also more likely to interrupt treatment (Kranzer et al., 2010). Various structural reasons, such as the location and operating hours of facilities have been provided for the reluctance of men to frequent healthcare facilities. Socio-cultural factors are known to influence male access to healthcare, since in many settings, seeking healthcare is viewed as a sign of weakness and manhood is associated with ‘risk taking, dominance and sexual conquest’ (Peacock et.al., 2008). These cultural norms are reflected in the results of two South African research studies that engaged urban minibus drivers where findings reveal that despite having a relatively good knowledge of HIV, minibus taxi drivers frequently engage in multiple and concurrent sexual relations, practice risky sexual behaviour and tend to use traditional medicines to protect themselves from HIV rather than accessing HIV testing and treatment services (Ncama et al., 2013; Mchunu et al., 2012). Therefore, it is apparent that gender dynamics can have a detrimental impact on male health, and make them vulnerable to chronic illnesses, in particular HIV. Nonetheless, there is still a lack of attention to men’s health in leading HIV research and funding is often angled towards other population groups such as pregnant women and children (Cornell et al., 2011).

In this paper, we provide a critical analysis of an independent, researcher-led communication intervention called Jiving with Science, where we used small media, edutainment and popular music to target minibus taxi drivers in rural KwaZulu-Natal. Edutainment is the ‘intentional placement of educational content in entertainment messages’ (Singhal & Rogers, 2002). Since its emergence in the 1950s, edutainment has evolved from the expert driven, information-orientated, targeted first generation strategies, to the participatory and collaborative second generation strategies, to the social critique and action media-style of third generation strategies (Fourie, 2011; Tufte, 2005). Edutainment is a potentially powerful HIV communication tool because individuals tend to ‘engage, identify and involve themselves strongly with the stories told in radio and television drama and when this is explored strategically, it may well contain the potential to articulate debate around difficult-to-talk about issues such as HIV’ (Tufte, 2005).

South Africans have relatively high levels of access to mass media channels such as television 73% and radio 68% (Statistics South Africa), and consequently, there has been a proliferation of mass media-based HIV edutainment campaigns, such as large-scale audio-visual, audio and print campaigns of The Soul City Institute (Tufte, 2008). Nevertheless, while these mass media communication campaigns may be effective to share broad information with large audiences, there is a need for more targeted media products to meet the specific health requirements of high risk population groups (Tanser et al., 2009). In this climate, small media, such as stickers, posters, audio CDs, videos and photographs have become popular tools in health interventions. These tools are relatively cheap and simple to produce and have become a feasible option for healthcare workers and researchers to create targeted interventions (Parker, Dalrymple, & Durden, 2000). Moreover, although small media products may be challenged by a lack of durability and an absence of established distribution structures (Parker et al., 2000), research has shown that in terms of HIV knowledge retention and HIV dialogue stimulation, exposure to small media can have similar effects to mass media (Bertrand, O’Reilly, Denison, Anhang, & Sweat, 2006).

Since we were operating in a rural community of relatively low literacy levels, in Jiving with Science, we designed an audio product that featured a selection of songs and stories rather than creating printed pamphlets, stickers or billboards (Leach, 1999). Moreover, as storytelling is part of everyday life of rural communities and therefore we adopted a narrative-based product since this seemed to be a ‘natural means to convey developmental messages’ (Fourie, 2011). We also decided to create a popular music-orientated product as most taxi drivers play music (usually very loudly) but often only have a couple of CDs to play.

The key assumption behind edutainment interventions such as Jiving with Science is that these instruments can potentially spark debate amongst audiences about relevant issues, which can lead to collective social change (Papa & Singhal, 2009). Taxis have long functioned in South Africa as sites of community discussion, dialogue and informal education (Hansen, 2006), and in this project, we aimed to harness this culture of ‘Taxi Talk’ by encouraging discussions between drivers and patrons about HIV in taxis as a first step towards bringing about social change. However, while the concept of Jiving with Science may have seemed exciting on paper, could this approach truly work? Could we use popular music, small media and edutainment to (1) reach local minibus taxi drivers, (2) improve community knowledge of HIV testing, (3) encourage uptake of local HIV testing and care services and (4) promote interpersonal dialogue about HIV? Below we use the results of a small-scale quantitative survey to provide some initial answers to this question and to inform a critical discussion about the potential use of the Jiving with Science concept in future interventions.

Methodology

Setting: This project was initiated by an international research facility based in the uMkhanyakude district of KwaZulu-Natal. This rural area is located about two hundred kilometres north of the largest provincial town of Durban, which is characterised by high levels of poverty. The total unemployment rate in this area was 52.6% at the time of the 2011 Census, rising to 61.9% among youth. HIV prevalence in the area is high (29% in the adult population aged 15-49 years in 2011) (Zaidi, Grapsa, Tanser, Newell, & Bärnighausen, 2013). HIV treatment and care has been delivered through a decentralised primary health care programme since 2004 (Houlihan et al., 2011). By 2010, 40% of the population lived in a household with at least one member in HIV care and 25% in a household with at least one member on ART (Bor , Herbst, Newell, & Bärnighausen, 2013). The scale-up of ART has had a profound impact on population-level mortality, with a rise in adult life expectancy of 11 years between 2003 and 2011 (Bor et al., 2013).

Target audience: Our primary target audience in this project were local drivers of minibus taxis and their patrons. In the uMkhanyakude district where the Centre operates there are approximately 400 Taxi drivers and an estimated 50-60,000 weekly users of local mini-bus taxis.

Product description: Jiving with Science consisted of a series of three audio CDs. Each CD comprised an informational narrative presented in Zulu, interspersed with popular music tracks, targeted health/HIV messages and calls to action. Key health issues and behaviour change goals were identified by conducting research into region-specific scientific data, interviewing scientific and community engagement staff and consulting community stakeholders. Data collected was used to design scripts in which health information was embedded in dialogue-rich, entertaining narratives. Partners in the music industry were motivated by Corporate Social Responsibility CSR agendas to waive production rights on specific popular music tracks. This allowed the product to be made on a low budget with each CD costing approximately R20 $2 US dollars to produce exclusive of salaries and other project running costs (for more production details please see Treffry-Goatley et al. 2013). The names of the CDs are:

  1. Uhlelo lukaMambiyela (Mam’Biyela’s story)
  2. Uhlelo lukaDJ Tira (DJ Tira’s story)
  3. Uhlelo lukaMroza (Mroza’s radio show)

For the sake of brevity, in this paper, we focus on the performance of the third CD, Uhlelo lukaMroza. The aim of this product was to improve public knowledge of the importance of regular and repeated HIV testing and to promote testing amongst individuals in stable relationships. The narrative in the CD is dialogue based, with the questions serving to promote critical thinking amongst listeners, encourage uptake of available health services and inspire dialogue about HIV.

Distribution strategy: Six hundred copies of Uhlelo lukaMroza were duplicated and freely distributed to appropriate project stakeholders. Mtubatuba Taxi Owners Association was a key partner, supporting engagement with drivers and assisting with the distribution of the CDs. The Association is responsible for 300 taxis and five of the formal taxi ranks in the local area. It hosted the project launch at the main taxi rank, which facilitated direct contact with 200 taxi drivers. We used the opportunity to engage with drivers and challenge them to make a positive change in their community by taking part in the project and playing the CDs frequently. We also used the launch to distribute the first two CDs. The Taxi Association took the lead for the distribution of the third CD, Uhlelo lukaMroza.

Product evaluation: The CDs were evaluated using two quantitative surveys (refer to Table One below). The aim of Survey one was to assess the feasibility and acceptability of this targeted intervention and to gain feedback to inform the development of the third CD. Once we had analysed this data and were assured that the intervention was feasible and had been accepted by local driver and their patrons, we proceeded to tailor the final CD to meet the musical preferences and health needs of the target group at hand. The second summative survey Survey two, on the other hand, was conducted in December 2011 and specifically evaluated the influence of Uhlelo lukaMroza, which had been released three months previously. In this paper, we focus on the results of Survey two since these are directly relevant to Uhlelo lukaMroza.

Table One: Quantitative Survey Details

Survey Two details: This convenience survey was designed to test the reach, coverage and frequency of the intervention, the impact on information recall and to assess whether the product had inspired dialogue about HIV in the taxi. In total, we interviewed 421 people over five days. The participants comprised 127 taxi drivers and 290 members of the general public. Using a convenience sampling methodology, five fieldworkers (three men and two women) were posted at five local taxi ranks for seven days. They approached all the taxi drivers and as many members of the public as possible on a given day.

Data analysis: Once the quantitative data had been collected, we used STATA statistical software programme version 11 to conduct descriptive analysis using Chi-square Fishers Exact Tests to examine associations between exposure to the CD and information recall, reported behaviour and taxi dialogue about HIV (

Results

Reponses rate: The response rates for Survey two were 290/346 (84%) and 127/173 (73%) for public and driver respondents respectively. The mean age of driver participants was 32 years old (21 to 62 years), which was slightly older than the public respondents’ mean age of 28 years (18 to 63 years). Moreover, while public respondents consisted of 128 male and 162 females, there were just four female drivers.

Exposure and frequency of use: In terms of our objective to reach taxi drivers, we found that 70 of the 127 (coverage = 55%) drivers reported that had been given the CDs. Regarding frequency of use, 35 (50%) drivers reported that they played CD 3 between 0-10 times, 26 (37%) that they played it more than 10 times and 72 (57%) reported that they had never played the CD. About one-quarter of the drivers 18/70 indicated that they were still using the CDs at the time and the remaining 52 respondents (74%) indicated that they had stopped using. In terms of reach amongst the general public, we found that 81 of the 290 coverage = 28% individuals that we interviewed could recall hearing the CD.

Impact on HIV testing knowledge: Concerning our objective to improve community knowledge of HIV testing, we found no significant association between exposure to CD and information recall, although there was a link between exposure to CD and drivers’ belief that stable partners should test for HIV see Table two below. Moreover, in terms of our objective to promote uptake of local testing treatment and care services, we did not find any association between participant exposure and reported behaviour change.

Table Two: Results of Survey Two

Inspiring interpersonal dialogue: With regards to our objective to inspire dialogue about HIV in taxis, we established that there was a significant association between reported engagement with a passenger about HIV and exposure to the CD. Furthermore, 42 of 70 60% drivers with exposure to CD reported hearing passenger dialogue about HIV in the taxi when the CD was playing See Table 2 above. When explored further, we discovered that there was a significant association between frequency of CD usage and driver engagement with passengers about HIV and reported discussion about HIV amongst passengers refer to Table Three below.

Table Three: Relationship between CD Use and Discussion about HIV in Taxis

Discussion

Study limitations: This project is an example of how small media can be used by health researchers to create targeted edutainment products. We viewed this intervention as an opportunity to engage with drivers, who value music and rarely visit health services (Mchunu et al., 2012). Nevertheless, a lack of durability and an effective distribution structure remain a challenge for this small media enterprise, with just over half of the drivers (n=70) and 81 passengers (28%) reporting exposure despite our attempt to work closely with the local Taxi Association. Perhaps if we experimented with newer media formats such as MP3 tracks shared on mobile phones or collaborated with local radio stations then we could extend the reach of this intervention.