Karin Hatzold of Population Services International (PSI) described
lessons learnt from the introduction of voluntary medical male circumcision in African countries. The
procedure has been recommended by the World Health Organization and UNAIDS since 2007, but implementation has been
patchy. While just under 12 million boys and men had been circumcised in 14
priority countries by the end of 2015, this was only 56% of the global
target that had been set for completion by that time.
Focusing on Zimbabwe, she said that a 2013 survey showed
that 68% of men were aware of circumcision as an HIV prevention method, 66% were
interested in circumcision for themselves and 64% said they intended to get
circumcised – but only 11% had actually been circumcised.
PSI used qualitative research and insights from marketing in
order to examine why there was such a large gap between intention and action. Through
this they developed a model to outline the path that men undertake on their
journey to circumcision and to identify possible marketing interventions.
This highlighted that even after men had learnt about male
circumcision and made an internal commitment to be circumcised, another stage
followed in which men anticipated the procedure and the healing process. Men
often experienced ‘cognitive dissonance’ between their belief in the long-term
benefits of circumcision (protection from HIV and sexually transmitted infections [STIs]) and concern about its
short-term consequences (pain during healing, abstinence from sex and time away
from work). This dissonance is strongest in adult men and is less common among adolescents.
Quantitative surveys were used to segment the male population of Zimbabwe
according to their needs, attitudes and behaviours in relation to male
Twenty-one per cent of
uncircumcised men were described as circumcision ‘enthusiasts’. They believe in
the procedure’s benefits but still have some anxieties. This
group has the greatest potential for interventions, as they are ready to go for
circumcision, but need some additional support to overcome cognitive
dissonance. They may be influenced by peers and social pressure.
Nineteen per cent of
uncircumcised men are described as circumcision ‘neophytes’. They have not
yet decided whether they want to be circumcised or not. They have a need for
more information about circumcision and interventions to strengthen motivation.
Seventeen per cent are seen as ‘embarrassed rejecters’. They have mostly
negative attitudes towards circumcision and minimal motivation. The attitudes
of their peers could have the greatest influence on them.
Other population segments are ‘scared rejecters’ (16%) and
the ‘highly resistant’ (22%). As there is less potential to convince these
groups, they are a lower priority for interventions. There is also a group of
men who have positive attitudes to circumcision like those of the ‘enthusiasts’
but who are less open to social pressure. As this is only 6% of uncircumcised
men, they are also not a priority for interventions.
The research suggested interventions which can help Zimbabwean men move
along the path towards circumcision. Outreach workers and marketing materials
now provide honest and detailed information about the procedure and healing
process, so as to more effectively deal with anxiety and cognitive dissonance.
In order to counteract short-term negative consequences,
some more immediate benefits are now more clearly communicated. As well as better
hygiene, there is also a focus on sexual appeal to female partners. Women may
be more sexually satisfied, due to intercourse lasting for longer.
Enthusiastic clients who have already been circumcised are
encouraged to act as advocates for the procedure, so as to tap into the
influence of peers and to provide social support for men considering the
intervention. Marketing materials have been created to help trigger these kind
Bertran Auvert of the French National Institute of Health
and Medical Research also outlined challenges and successes in promoting male
circumcision. His example came from Orange Farm, a township near Johannesburg,
South Africa, where the proportion of adult men circumcised rose from 13 to
55% in the three years from 2008, but then stopped rising. As in Zimbabwe, he
said that the challenge was not to convince men of the benefits of
circumcision, but to help men take the final step and attend a circumcision
An intervention he and his colleagues have recently piloted
started with household visits, in which men were offered one-to-one discussions
based on the motivational interviewing technique (a goal-orientated style of
counselling, which aims to help clients overcome ambivalence). Men could have
up to three sessions, but most decided to be circumcised after one motivational
interview of around an hour.
Financial compensation of around USD$18 (equivalent to two
or three days’ wages) was offered to compensate for the time the procedure and
its recovery takes. This support was only offered during the nine-week period
in which the pilot was run – the deadline also incited men to take action.
Prior to the intervention, 57% of men in a random household
sample were circumcised. The intervention raised rates to 81%.
Among men who were circumcised, 83% said they wouldn’t have
done it without the motivational interviewing and 40% wouldn’t have done it
without the financial compensation.