Leadership and financial incentives hold key to increasing voluntary male circumcision

An evidence review has found that financial incentives framed as ‘fair compensation’ and education or counselling delivered by religious and other influential figures are the most effective ways to increase demand for voluntary medical male circumcision (VMMC) in sub-Saharan Africa.

Researchers analysed 18 quantitative and qualitative VMMC studies conducted in South Africa, Zambia, Tanzania, Kenya, Uganda, Zimbabwe and Malawi between 2014 and 2018. The size of participants varied, from around 520 to 145,000 in quantitative studies and from 10 to 290 in qualitative research.

VMMC can reduce female-to-male sexual HIV transmission by 60%, causing UNAIDS and the World Health Organization to recommend that 90% of men aged 10 to 29 years in 14 sub-Saharan Africa countries should be circumcised by 2021. Advances in technology and increased VMMC availability have contributed to recent increases in uptake but some target countries are lagging behind due to a lack of demand.

To add to the growing body of evidence on VMMC, researchers analysed demand-creation interventions from the selected studies using four broad categories: financial incentives, counselling or education, involvement of influencers and novel information delivery. Some studies under review used a combination of these approaches.

All categories were found to increase uptake or prevalence of VMMC, with financial incentives and counselling from influencers most effective. Interventions were found to be more successful if the target population judged them to be appropriate and acceptable, if they were delivered by people with relevant personal experience, and if they addressed broader social and cultural influences.

Financial incentives, such as food and transport vouchers or direct cash payments, produced the largest relative impact, with men up to seven‐times more likely to undergo VMMC in intervention arms than in control groups. However, due to a low level of acceptance of VMMC, the overall increase in the total uptake was fairly small.

In general, the higher the compensation level offered the greater the impact, however incentives that were presented as ‘fair compensation’ were more acceptable, and therefore more effective, than prizes. For example, one qualitative study recounted older men’s negative responses to a Smartphone lottery, showing the intervention to be counterproductive as it made this group suspicious of VMMC and undermined trust. The reviews’ authors also highlight the need to monitor the “coercive potential” of offering financial rewards for VMMC as qualitative data included in the review suggests this has the potential to impede a programme’s effectiveness.

The intervention creating the greatest population‐level impact on VMMC prevalence (a 23% increase) was found to be a combined intervention that trained religious leaders on the benefits of VMMC so they could influence men in their communities to undergo the procedure.

In contrast – and contradicting previous evidence that women can have a significant influence on men’s decisions to become circumcised – interventions working with the female partners of men were found to be ineffective in increasing uptake. In qualitative studies, women expressed discomfort in delivering messages about VMMC to partners. However, group education delivered to both partners, and an intervention that combined the use of female influencers with travel vouchers, were found to be effective.

The review also found VMMC peer‐referral schemes did not increase uptake. In a similar way to female partners, men reported being reluctant to discuss the issue as it was seen as potentially sensitive. However, further research into peer-led interventions is warranted, as no randomised control trial on this intervention was included in the current review.

The contrast between the impact of different influencers suggests that, due to their respected role in communities, church leaders and other similarly-influential figures could play a key role in disseminating VMMC information in ways that make the procedure more socially acceptable.

Group education or counselling was also found to be effective, increasing the likelihood of VMMC around 2.5‐fold, with an 8% to 20% absolute increase in uptake compared to control groups. Group sessions were found to be more appropriate for younger men, who placed greater value in peer acceptance and support.

Technology was found to be useful for increasing VMMC demand while reducing the costs of demand-creation programmes. Motivational, encouraging messages were found to have a greater impact than messages focusing on health promotion.

The review shows that a range of demand-creation interventions can increase VMMC uptake, with appropriate financial incentives and respected community figures most effective in encouraging men to get circumcised.

The review’s authors call for larger studies on VMMC with longer follow-up times so the impact of behavioural change interventions can be fully analysed.