Programme science research on medical male circumcision scale-up in sub-Saharan Africa

Gray, Ronald H.; Wawer, Maria J.; Kigozi, Godfrey

doi:10.1136/sextrans-2012-050595

Cited by 29 publications

(28 citation statements)

References 24 publications

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“…While it is generally assumed that low VMMC uptake requires more demand generation [11], early service delivery experiences [12]–[14] indicate a need to nuance this assumption. Matching the supply of VMMC services to fluctuating demand levels, offering services in places and at times that are convenient for men, and addressing disproportionate uptake between younger (less at-risk) and older (more at-risk) men are issues highlighted in case studies on service delivery roll-out [12]–[14].…”

Section: Introductionmentioning

confidence: 99%

Behavior Change Pathways to Voluntary Medical Male Circumcision: Narrative Interviews with Circumcision Clients in Zambia

et al. 2014

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As an HIV prevention strategy, the scale-up of voluntary medical male circumcision (VMMC) is underway in 14 countries in Africa. For prevention impact, these countries must perform millions of circumcisions in adolescent and adult men before 2015. Although acceptability of VMMC in the region is well documented and service delivery efforts have proven successful, countries remain behind in meeting circumcision targets. A better understanding of men's VMMC-seeking behaviors and experiences is needed to improve communication and interventions to accelerate uptake. To this end, we conducted semi-structured interviews with 40 clients waiting for surgical circumcision at clinics in Zambia. Based on Stages of Change behavioral theory, men were asked to recount how they learned about adult circumcision, why they decided it was right for them, what they feared most, how they overcame their fears, and the steps they took to make it to the clinic that day. Thematic analysis across all cases allowed us to identify key behavior change triggers while within-case analysis elucidated variants of one predominant behavior change pattern. Major stages included: awareness and critical belief adjustment, norming pressures and personalization of advantages, a period of fear management and finally VMMC-seeking. Qualitative comparative analysis of ever-married and never-married men revealed important similarities and differences between the two groups. Unprompted, 17 of the men described one to four failed prior attempts to become circumcised. Experienced more frequently by older men, failed VMMC attempts were often due to service-side barriers. Findings highlight intervention opportunities to increase VMMC uptake. Reaching uncircumcised men via close male friends and female sex partners and tailoring messages to stage-specific concerns and needs would help accelerate men's movement through the behavior change process. Expanding service access is also needed to meet current demand. Improving clinic efficiencies and introducing time-saving procedures and advance scheduling options should be considered.

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Section: Introductionmentioning

confidence: 99%

Behavior Change Pathways to Voluntary Medical Male Circumcision: Narrative Interviews with Circumcision Clients in Zambia

et al. 2014

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“…To date, no trials of interventions to increase demand for VMMC have been conducted and recent reviews have identified this as a priority for implementation science research. 6,8 …”

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confidence: 99%

Effect of Providing Conditional Economic Compensation on Uptake of Voluntary Medical Male Circumcision in Kenya

Thirumurthy

Masters

Rao

et al. 2014

JAMA

117

133

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IMPORTANCE Novel strategies are needed to increase the uptake of voluntary medical male circumcision (VMMC) in sub-Saharan Africa and enhance the effectiveness of male circumcision as an HIV prevention strategy. OBJECTIVE To determine whether small economic incentives could increase circumcision prevalence by addressing reported economic barriers to VMMC and behavioral factors such as present-biased decision making. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial conducted between June 22, 2013, and February 4, 2014, among 1504 uncircumcised men aged 25 to 49 years in Nyanza region, Kenya. VMMC services were provided free of charge and participants were randomized to 1 of 3 intervention groups or a control group. INTERVENTIONS Participants in the 3 intervention groups received varying amounts of compensation conditional on undergoing circumcision at 1 of 9 study clinics within 2 months of enrollment. Compensation took the form of food vouchers worth 200 Kenya shillings (≈US $2.50), 700 Kenya shillings (≈US $8.75), or 1200 Kenya shillings (≈US $15.00), which reflected a portion of transportation costs and lost wages associated with getting circumcised. The control group received no compensation. MAIN OUTCOMES AND MEASURES VMMC uptake within 2 months. RESULTS Analysis of data for 1502 participants with complete data showed that VMMC uptake within 2 months was higher in the US $8.75 group (6.6%; 95% CI, 4.3%–9.5% [25 of 381]) and the US $15.00 group (9.0%; 95% CI, 6.3%–12.4% [34 of 377]) than in the US $2.50 group (1.9%; 95% CI, 0.8%–3.8% [7 of 374]) and the control group (1.6%; 95% CI, 0.6%–3.5% [6 of 370]). In logistic regression analysis, the US $8.75 group had significantly higher VMMC uptake than the control group (adjusted odds ratio [AOR] 4.3; 95% CI, 1.7–10.7), as did the US $15.00 group (AOR 6.2; 95% CI, 2.6–15.0). Effect sizes for the US $8.75 and US $15.00 groups did not differ significantly (P = .20). CONCLUSIONS AND RELEVANCE Among uncircumcised men in Kenya, compensation in the form of food vouchers worth approximately US $8.75 or US $15.00, compared with lesser or no compensation, resulted in a modest increase in the prevalence of circumcision after 2 months. The effects of more intense promotion or longer implementation require further investigation.

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“…SYMMACS results contribute to the scant literature on VMMC service delivery: on human resource issues [11], [12], disposable versus reusable instruments [13], the safety of task-shifting [14], and descriptions of programs implementing efficiency elements in KE [15], RSA [16], TZ [17], and Uganda [18]. In addition, they have prompted policy debate and programmatic action in all four countries where they have been presented in in-country diseemination conferences, scientific meetings, workshops, and other venues.…”

Section: Discussionmentioning

confidence: 94%

Systematic Monitoring of Voluntary Medical Male Circumcision Scale-Up: Adoption of Efficiency Elements in Kenya, South Africa, Tanzania, and Zimbabwe

Bertrand¹,

Rech

Aduda³

et al. 2014

PLoS ONE

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BackgroundSYMMACS, the Systematic Monitoring of the Voluntary Medical Male Circumcision Scale-up, tracked the implementation and adoption of six elements of surgical efficiency— use of multiple surgical beds, pre-bundled kits, task shifting, task sharing, forceps-guided surgical method, and electrocautery—as standards of surgical efficiency in Kenya, South Africa, Tanzania, and Zimbabwe.Methods and FindingsThis multi-country study used two-staged sampling. The first stage sampled VMMC sites: 73 in 2011, 122 in 2012. The second stage involved sampling providers (358 in 2011, 591 in 2012) and VMMC procedures for observation (594 in 2011, 1034 in 2012). The number of VMMC sites increased significantly between 2011 and 2012; marked seasonal variation occurred in peak periods for VMMC. Countries adopted between three and five of the six elements; forceps-guided surgery was the only element adopted by all countries. Kenya and Tanzania routinely practiced task-shifting. South Africa and Zimbabwe used pre-bundled kits with disposable instruments and electrocautery. South Africa, Tanzania, and Zimbabwe routinely employed multiple surgical bays.ConclusionsSYMMACS is the first study to provide data on the implementation of VMMC programs and adoption of elements of surgical efficiency. Findings have contributed to policy change on task-shifting in Zimbabwe, a review of the monitoring system for adverse events in South Africa, an increased use of commercially bundled VMMC kits in Tanzania, and policy dialogue on improving VMMC service delivery in Kenya. This article serves as an overview for five other articles following this supplement.

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Programme science research on medical male circumcision scale-up in sub-Saharan Africa

Cited by 29 publications

References 24 publications

Behavior Change Pathways to Voluntary Medical Male Circumcision: Narrative Interviews with Circumcision Clients in Zambia

Behavior Change Pathways to Voluntary Medical Male Circumcision: Narrative Interviews with Circumcision Clients in Zambia

Effect of Providing Conditional Economic Compensation on Uptake of Voluntary Medical Male Circumcision in Kenya

Systematic Monitoring of Voluntary Medical Male Circumcision Scale-Up: Adoption of Efficiency Elements in Kenya, South Africa, Tanzania, and Zimbabwe

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