Introduction UNAID S has recommended that in 14 countries across sub‐Saharan Africa ( SSA ), 90% of men aged 10 to 29 years should be circumcised by 2021 to help reduce transmission of HIV . To achieve this target demand creation programmes have been widely implemented to increase demand for Voluntary Medical Male Circumcision ( VMMC ). This review explores the effectiveness of demand creation interventions and factors affecting programme implementation. Methods We completed a mixed methods systematic review searching Medline, Embase, Global health, psyc INFO and CINAHL databases in August 2018 with no time restrictions. Demand creation interventions conducted in SSA were categorized and quantitative data about VMMC uptake was used to compare relative and absolute effectiveness of interventions. Qualitative data were summarized into themes relevant to the delivery and impact of programmes. Results and discussion Eighteen of the 904 titles were included in the review. Effective interventions were identified in each demand creation category: financial incentives, counselling or education, involvement of influencers and novel information delivery. Of the 11 randomized controlled trials ( RCT s), the greatest absolute impact on VMMC prevalence was seen with a complex intervention including VMMC promotion training for religious leaders (compared to control: 23% (95% CI 22.8 to 23.8) absolute increase; odds ratio ( OR ) 3.2 (1.4 to 7.3)). Financial incentives generally produced the largest relative effects with men up to seven‐times more likely to undergo VMMC in the intervention arm compared to control (adjusted OR 7.1 (95% CI 2.4 to 20.8), 7.1% (3.7 to 10.5) absolute increase). Qualitative findings suggest that interventions are more impactful when they are judged appropriate and acceptable by the target population; delivered by people with relevant personal experience; and addressing broader social and cultural influences through partnership with and education of community leaders. Conclusions A range of demand creation interventions can increase VMMC uptake. The most acceptable and effective interventions are financial incentives framed as fair compensation (relative effect) and programmes of education or counselling delivered by people who are influential in the community (absolute effect). Future research should include larger studies with longer follow‐up and a consistent definition of VMMC uptake.

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Underestimating the true impact of obesityThe ever-increasing burden that obesity exerts on population health was recently explored in The Lancet Public Health by Solja Nyberg and colleagues. 1 The authors measured the loss of diseasefree years attributable to major noncommunicable diseases (NCDs) in obese adults compared with those who were normal weight. Individuals lost 3-4 more disease-free years if they were mildly obese and 7-8 more disease-free years if they were severely obese. These results show the alarming extent of obesity's impact on health; however, the true effect is likely to be even higher than reported.The decision to use the six commonest NCDs could have led to an underestimation of the true effect size because obesity contributes a large morbidity burden through diseases not included in their analysis, such as musculoskeletal conditions and depression. 2 Lower back pain has been extensively linked to increased bodymass index 3 and is the leading cause of disability-adjusted life-year loss globally. 4 Furthermore, as shown by the authors, the effect of their chosen conditions, particularly type 2 diabetes, was likely to be underestimated as only data from hospital and death registries were used. This data selection omits the huge burden of obesity-associated morbidity that exists solely in primary care. 5 It also could explain part of the considerable difference in disease-free years lost between mild and severe obesity; co-morbid conditions suffered by those with mild obesity are less likely to be severe enough to require inpatient management.The effect of obesity through NCDs is likely to be more alarming than reported and this effect permeates through all social classes. More must be done through public health policy to tackle all levels of obesity.We declare no competing interests.