MALE CIRCUMCISION FOR HIV PREVENTION
Voluntary medical male circumcision (VMMC) is an important part of HIV prevention approaches in some African countries with high rates of HIV infection. Yet even when services are readily available and of high quality, persuading men to get circumcised is not easy. Most say that they are willing to do it to help protect themselves – but few actually follow through.
In Zambia and Zimbabwe, two countries that promote VMMC, we applied research tools grounded in behavioral science to understand how people relate to a particular product. We found that a range of beliefs, emotions, and perceptions shaped men’s attitudes towards circumcision
– and that these changed over time. We mapped the range of emotional and behavioral barriers that could stop a man from following through to get circumcised. And we segmented men into groups with distinct profiles who would respond best to specific messages tailored to their concerns. This was the basis for the design of new interventions to help persuade men to undergo circumcision, reducing the risk of HIV infection for themselves and their loved ones.
Bill & Melinda Gates Foundation
Zambia & Zimbabwe
Driving through urban slums in Zambia, you see posters along the roads encouraging men to undergo voluntary medical male circumcision (VMMC). As the radio plays in the background, the stern voice of a county health official talks about why VMMC is needed to stop the spread of HIV. The global health community has been trying to conquer the disease since cases were first noticed in the 1980s. HIV is a manageable condition for those who can reliably access medications, but after decades of research, there is still little prospect of a vaccine or a cure. In the meantime, governments in some countries in sub-Saharan Africa have been promoting VMMC to reduce transmission of the virus.
While not as effective as a vaccine, VMMC has been shown to lower the risk of a man getting HIV through sex with an HIV-positive woman by 60%. With the support of UNAIDS and other global health bodies, VMMC has been widely promoted in 15 southern and eastern African countries where HIV infection rates are high and relatively few men are circumcised. The stakes are high: UNAIDS and the World Health Organization estimated that by increasing the rate of circumcision to 80%, more than 3.4 million HIV infections could be averted over a 10-year period.
The VMMC ad campaigns appear highly effective at raising awareness, with 60-70% of uncircumcised men declaring an intention to undergo VMMC – yet only about one in ten of them actually follow through. What could be the cause of such a disparity? What kinds of barriers do men face to getting circumcised? And how can we encourage more of them to go through with the procedure?
In 2014, Final Mile joined a consortium of organizations to help the governments of Zambia and Zimbabwe tackle these questions. Working with Ipsos Healthcare, Upstream Thinking, PSI, Society for Family Health, and the Bill & Melinda Gates Foundation, our goal was to find out what underlay the large gap between intention and action when it came to VMMC, and to test interventions to reduce that gap, so that more men would get circumcised.
Zambia and Zimbabwe have been severely impacted by the HIV epidemic, and both had been running campaigns to encourage VMMC. But despite their efforts and considerable progress, uptake of the procedure was falling short of the countries’ ambitious targets, and the governments didn’t have detailed enough data to explain why. We didn’t want to limit our inquiry to the practical obstacles that might prevent men from getting circumcised. Instead, we wanted to take a holistic and systematic approach, one that also examined the beliefs and feelings of men – and those around them – and the mental models that they used. Our goal was to understand how all these factors might influence a man’s behavior at different stages along his journey toward VMMC.
While intention is essential, it is insufficient when it comes to behavior change, action gaps are commonplace across a range of health behaviors
Mapping the journey to VMMC
Having gleaned useful background information on barriers to VMMC by reading previous studies, our next step was journey mapping, a technique commonly used in consumer marketing to understand how a person relates to a product. Journey mapping assumes that that relationship is not static – at different times, a person will have varying thoughts and feelings about the product. We believed this would apply to men and VMMC, too. Across the two countries we interviewed 150 men, along with 650 wives or girlfriends, close friends, parents, community leaders, and VMMC service providers, to get an all-round view of the influences on a man’s decision-making process. The research effort was led by our consortium partner, Upstream.
From these interviews emerged a map of the journey that men followed, which fell into three stages: first, awareness of VMMC as an HIV prevention method and belief in its benefits (we called this “Relate”), followed by a commitment to getting circumcised and scheduling an appointment for the procedure (“Anticipate”); and last, getting it done and – ideally – advocating for other men to undergo VMMC (“Relief”). For each stage, we sketched in the beliefs, motivations, influences, barriers, and triggers that could facilitate or hinder a man’s progress to the next stage.
Mapping barriers by each stage of the man’s journey to VMMC is crucial in designing timely and specific interventions
Deepening the picture
This initial picture needed greater depth and texture, and we got it through the EthnoLab™, the research technique designed by Final Mile and inspired by behavioral science. Around 200 men, their partners, and service providers in each country took part in a decision-making game. They voted on a range of responses to various scenarios designed to test our initial hypotheses about the emotions, mental models, and biases underlying men’s behavior regarding VMMC.
With the EthnoLab behind us, we synthesized the data from it and from the journey mapping into a single detailed framework. It depicted not just the three basic stages that a man goes through to get circumcised – Relate, Anticipate, and Relief – but also the range of barriers that might prevent him from progressing from one stage to the next. These barriers were of several types: anticipation of pain, anticipation of loss, distrust, uncertainty, shame, and finding the benefits of VMMC to be irrelevant. Crucially, we found that the precise nature of those barriers varied from stage to stage. For instance, when first thinking about VMMC in the Relate stage, a man might anticipate the pain of the surgical procedure, but once in the Anticipate stage, as the date nears, he might start looking further ahead to the pain associated with the healing period. Similarly, in the Anticipate stage a man might worry about feeling ashamed when he goes to the clinic for the circumcision. During the Relief stage this is no longer a relevant barrier, but he may feel shame about telling other people what he’s done – which will stop him from being an advocate for VMMC with other men.
Rather than focusing on intention, addressing near-term concerns or reducing friction helps in behavior change
We identified the influencers most likely to help a man overcome each and every barrier and move forward to the next stage, thus closing the intention-to-action gap. Our research also revealed that the optimum path to VMMC requires that men have control over three dynamics during their journey. The first of these is the time needed to assimilate one’s beliefs and feelings about VMMC. The second is a sense of self-preservation as VMMC leads to a healthier lifestyle with both short- and long-term benefits. The last dynamic is certainty over the timeline of the whole process.
Successful strategies for moving men from the Relate stage all the way to the Relief stage would need to address these dynamics, allowing men to come to terms with their feelings and doubts about VMMC, communicating the benefits credibly in order to outweigh the near-term negative consequences, and creating a sense of urgency to stop men from procrastinating indefinitely.
Different men, different journeys
Segments prioritized for intervention design
Armed with a good understanding of the stages in a man’s journey toward VMMC, and the barriers that could prevent him from progressing, we now had to turn this information into useful and effective interventions. By definition, not every man is at the same stage or facing identical barriers, and indeed, “one-size-fits-all” campaigns for VMMC hadn’t worked well. We needed to be able to distinguish between different groups of men, and design interventions to appeal to them. Again, we turned to an approach inspired by the private sector – market segmentation. Unlike our qualitative methods for the journey mapping and EthnoLab™, segmentation is a quantitative approach. We conducted a more in-depth survey of the beliefs, feelings, and behaviors of 2,000 men each in Zambia and Zimbabwe, and used computer algorithms to analyze their responses according to the categories in our behavior framework. This produced seven segments of the male population in Zambia, and six in Zimbabwe. Each segment had a distinct character in terms of men’s attitudes and behaviors around VMMC. We used the detailed data on each segment to develop a profile of a typical man in that segment – his demographics, HIV risk behaviors, his values and aspirations, how he felt about VMMC, and who he trusted most on the subject.
Turning insights into interventions
We took these segment profiles into design workshops, where we combined our insights with the experience and expertise of marketing and communications experts, health ministry officials, VMMC program implementers, and community mobilizers – the people who first approach men to talk to them about VMMC and try to sign them up. As with our initial research, our approach was to put the man’s needs and values at the center of the design process. The participants brainstormed ideas for interventions for each segment, to address the specific emotional and behavioral barriers of men in the segment and move them along the path to VMMC. We worked with these stakeholders to design prototypes for field testing with the highest-priority segments (the men at most risk of HIV and/or most susceptible to change).
Once we had refined the prototypes based on feedback from the field testing, we piloted the most promising ones. In Zimbabwe, we tested messages for community mobilizers to use to address men’s specific concerns about VMMC, depending on their segment profile, such as worries about maintaining their sexual appeal, or the emotional benefits of the protection offered by VMMC. We designed a “pain-o-meter” to offer relatable points of comparison for the degrees of pain involved at each step of the procedure and during healing. In Zambia, tools included a locally adapted version of the pain-o-meter and, for another segment of men, a flipchart to walk them through each step of the procedure and allay their concerns.
Just as important was a simple tool to help community mobilizers quickly identify which segment a man belonged to, on the basis of his responses to a handful of questions. This meant that mobilizers could grab a man’s attention with the information he’d be most likely to want, and address his concerns quickly and effectively.
Public health agencies in Zambia and Zimbabwe are working with several implementing partners to update their VMMC strategies based on our findings. Our holistic and integrated approach to this public health issue provides a more systematic solution, because it takes into account the psychology and decision-making of the person at the center of the problem, rather than just an analysis of external factors.
We have also used the behavioral framework when offering technical assistance to other countries in the region working on VMMC, and experience shows us it’s equally useful there, when adapted to take into account the local context. We developed a series of tools for program planners and implementers so that they can identify opportunities for new interventions, define segments of men to target, and design and improve interventions to address specific barriers. We believe our approach holds promise for fostering better health through behavior change not just for VMMC, but for other health issues beyond HIV, too.