Centre for HIV and AIDS Prevention Studies (CHAPS) (Frade); University of Houston (Friedman); CHAPS (Rech); and Reed College (Wilson)
“Voluntary medical male circumcision (VMMC) reduces HIV transmission by between 51 and 76 per cent, yet take-up of this fully subsidised service remains low in much of the region of the world most heavily afflicted with the HIV/AIDS pandemic (WHO 2014).”
To provide evidence on the barriers to VMMC take-up, the International Initiative for Impact Evaluation (3ie) commissioned a randomised controlled field experiment in Soweto, South Africa to test whether postcards with different messages, and the offer of compensation for attending a consultation, increased uptake of VMMC services. The study was undertaken in order to learn about barriers to take-up of VMMC and potential policy levers that could be pulled to increase the number of men in South Africa who choose to undergo VMMC procedures and reduce the spread of HIV. The research forms part of a series of seven studies undertaken in sub-Saharan Africa that investigate ways to increase the demand for VMMC. In late 2013, 3ie awarded grants to seven project teams of implementers and researchers to pilot innovative programmes for increasing VMMC demand and to conduct rapid impact evaluations of those programmes.
This study tests a particular marketing strategy for encouraging take-up of VMMC services. The project distributed 6,000 postcards in Soweto, with six different combinations of messages, including an offer of financial compensation conditional on attending a VMMC consultation, a challenge message (‘Are you tough enough?’), and information about partner preferences (‘two out of three partners of uncircumcised men prefer circumcised men’). The most basic version of the postcard only included a statement about the 51 to 76 percent reduction in HIV transmission, and further messages for the other two postcard versions were added to this statement. The study then measured and compared the rate of take-up of the circumcision procedure as well as consultations and text messages and calls to request more information for each of the six postcard types.
The results are meant to provide evidence about which are most likely to encourage take-up of VMMC, and in particular, which are most effective in encouraging take-up among those who are most at risk for HIV infection, thereby dramatically increasing the effectiveness of provision of VMMC to reduce HIV transmission rates. Besides informing policy, this is relevant for any organisation or government considering message delivery mechanisms of all sorts (radio, TV, billboards, etc.).
The paper includes a discussion on the evaluation questions, the intervention and its theory of change, the study timeline, and the main methodology of the study.
The evaluation questions are:
- How responsive is take-up of VMMC to the offer of transportation reimbursement (R100) for completing the VMMC consultation?
- How responsive is take-up VMMC to the provision of information about partner preferences?
- How responsive is take-up of VMMC to creative advertising messages that link the VMMC decision to ideas of masculinity?
To offer just a brief overview of the results of the study, the results indicate that modest compensation offer (i.e. R100 or approximately US$10) conditioned on the VMMC consultation increased take-up of the VMMC procedure by 2.5 percentage points (p-value=0.000), or a 400 percent increase relative to take-up in the control arm. Simply adding the challenge ‘Are you tough enough? to the basic postcard increased take-up of the VMMC procedure by 1 percentage point (p-value=0.03), or a 167 percent increase relative to take-up in the control arm. However, adding the challenge to the compensation postcard appears somewhat to have reduced the effectiveness of the compensation postcard, and adding the compensation offer reduced the effectiveness of the challenge (The report suggests further research to explore this). Comparing the simplest version of the postcard with and without information about partners preferring circumcised men, no differences were seen between the two groups.
The results of the analysis yield several key policy implications. “First, simple advertising of modest conditional compensation, in which the compensation is conditioned on the VMMC consultation, may generate a noticeable increase in take-up of the VMMC procedure. Second, framing the VMMC decision with a prompt, ‘Are you tough enough?’, following the ‘51 per cent to 76 per cent’ statement also generates a statistically significant increase in take-up of the VMMC procedure.”
The study suggests that this may be a cost-effective method of preventing new HIV-infections. The cost of printing and distributing a postcard is relatively small, and the R100 (US$10) compensation is disbursed only to men attending a VMMC consultation, and the study showed that the vast majority of men attending a consultation complete the VMMC procedure. As evidence indicates that a single VMMC in a high HIV prevalence, low male circumcision setting averts between 1/5 and 1/15 new HIV infections (UNAIDS/WHO/SACEMA Expert Group 2009), this is a cost worth considering.
The report also looks at the implications for future research. “First, future research should examine the effects of implementing these (or similar) advertising interventions at scale. Second, although ‘Are you tough enough?’ generated a substantial increase in VMMC take-up, future research may be able to identify more effective advertising messages. Third, future research should examine the effects of these interventions in other high HIV prevalence, low male circumcision settings.”