"Radio is not a means in and of itself. It’s the air war that supports the ground troops." MCHIP Chief of Party
This case study, based upon randomised control trial evidence for voluntary medical male circumcision (VMMC) as HIV prevention in the Iringa region of Tanzania and Zimbabwe, describes both the age distribution of clients accessing different VMMC services and the demand creation using interpersonal communication (IPC) and supply side activities that country programmes have implemented to increase service uptake, including their successes, lessons learned, and recommendations. It is a United States Agency for International Development (USAID) AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1, and Maternal and Child Health Integrated Program (MCHIP) review of programmes.
The study used informant interviews with "…in Tanzania, ...Ministry of Health and Social Welfare (MOHSW) clinicians, medical officers, and program staff; MCHIP program staff; and a USAID HIV prevention advisor. In Zimbabwe, respondents comprised MOHCW [Ministry of Health and Child Welfare] and PSI [Population Services International] VMMC program staff, University of Zimbabwe faculty, HIV counseling and testing program staff, service providers, and a Member of Parliament." Triangulated with programme monitoring data and a review of relevant literature and documentation, the case study describes programme service delivery as:fixed sites within or near existing health facilities, mobile sites (tents or prefabricated structures), and outreach sites in clinics or schools, offering both year-round service and campaign service delivery for high volume in a short time span.
In Iringa, Tanzania, campaigns coincide with school breaks and last 6-8 weeks. "The team and site managers review VMMC data daily from across all campaign sites to determine whether they have saturated a catchment area. If they have circumcised fewer clients than expected, they work with the mobilization team to attract more clients." The research in Tanzania found that the highest numbers of VMMCs delivered through campaigns were among 10- to 14-year-olds, followed by 15 to 19 and 20- to 24-year-olds. In Zimbabwe, outreach is the main mode of service delivery and can include transportation vouchers through contracts with commuter buses in urban and rural areas. Traditionally circumcising communities receive VMMC services in traditional settings and initiation camps in rural areas outside of health care facilities, using large tents for the surgical procedures and smaller tents for individual counseling and HIV testing. "Over 4,000 males have been circumcised in two consecutive years at these mobile sites....Posters indicating opening times and services days are created prior to the campaign start and displayed in public places. To increase service delivery efficiency, voluntary HIV testing and counseling is offered during outreach activities and at the health care facility level in the communities prior to and during the campaign."
On the demand creation side: "Iringa’s program uses interpersonal communication (IPC), mass media, and print media during campaigns and non-campaigns to create awareness about VMMC services and to engage community members. A combination of stickers, posters, public address systems, peer educators, radio, billboards, face-to-face communication, wrist bands, t-shirts and bandanas are used to reach target populations at schools, local bars, clubs, bus stops, shops, market places, and football fields."
The campaign programme liaises with local committees that include district officials, health facility staff, and international and community-based organisations (CBOs), which submit proposals for VMMC demand creation and are given some monetary support for activities. Experiential media (a cross-media grouping of two-way interactions that include "direct physical immersion into the activities") companies use music, dance, drama, sports, and other approaches to attract crowds and provide peer educators a chance to address questions. Radio advertising can include men and women speaking about VMMC, service providers discussing their training, and announcers listing service delivery sites. There is a toll-free phone line for information, service delivery sites, and a series of post-operative informational messages. Religious, village, and school leaders and local hosts are engaged in demand creation and in providing support for accommodations and meals for team members. Messages are adapted for age groups and for urban/rural differences in audience.
Routine service delivery communication "relies heavily on radio advertisements, some print media such as brochures and posters, and community mobilizers who work with partner, community-based, and USG [US government] agencies to visit market places and communities around fixed sites to speak with people about the benefits of VMMC and to remind them of the service delivery hours at fixed sites." There is an SMS (text) system with toll-free numbers advertised by radio.
In Zimbabwe, "[t]he program conducted formative research to gain insight into the target audience and focus demand creation efforts. Based on the research findings, key demand creation objectives are to increase social support for VMMC from peers, partners, and local leadership, and to create positive attitudes towards VMMC. The program uses a multimedia mix of small group discussions, community dialogues, road shows with dance competitions, drama, radio spots and call in shows, in-store advertising, press, and static and electronic billboards. A hotline also provides potential clients with information."
Celebrities from the sports and music industries develop songs to attract youth 13-29 years of age on local radio and television stations. "Winky D songs link VMMC with smartness, style, fashion, and confidence. Accompanying posters and CDs featuring Winky D are distributed in schools and colleges. Organizations like the Football Union and Grassroots Soccer have also trained their soccer players to conduct small group discussions on VMMC and create awareness."
Collaboration with community-based youth groups and organisations and with local leaders, such as chiefs, headmasters, pastors, and political councilors, to create demand includes sensitising to build support, providing talking points, and offering refresher training. There is a system of VMMC champions who are encouraged to “Bring a Buddy" through training sessions and brainstorming activities on how to attract more clients. Messaging is also created to mobilise women and to engage older men in workplaces, churches, and at home using a combination of brochures, posters, television, radio, IPC, and small group discussions to engage its audience. Community-based mobilisers are registered with the national- and district-level AIDS councils to track clients from demand creation through post-operation reviews and counseling.
During campaigns, larger numbers of collaborators, including youth groups and community leaders, are included in sensitisation meetings. Local chiefs and councilors conduct community dialogues. Headmasters talk with students and parents, addressing fears and beliefs. Leaflets are offered; mobilisers go door-to-door, to local soccer matches, and to churches, as well as circulating with bullhorns. "[R]oad shows featuring music and dance competitions around VMMC are implemented to create a 'buzz' and attract large crowds of people. During the road shows, information booths are set up where the community mobilizers register potential clients for follow up. Posters, banners, and leaflets highlighting the campaign dates and outreach sites are put up in grocery stores and at schools and clinics." Two to three weeks prior to a campaign, mass media message frequency is increased, including the use of radio spots, radio talk shows with VMMC experts, posters, and press coverage. "Radio spots featuring Winky D and female DJs to appeal to women are also aired in major supermarkets. Television talk shows discussing VMMC benefits and addressing myths are also increased to raise awareness and interest in the service."
Routine service delivery is supported by information booths at marketplaces and visits to workplaces and churches to engage potential clients. "In 2012, the demand creation team began to experiment with a new strategy called the 'blitz.' The goal of the blitz is to identify a geographic area near a fixed site using data on population density and HIV risk and saturate it with messages for one week."
Lessons and recommendations related to demand creation include:
- Demand creation is vital "to build awareness, dispel myths, and change social norms to increase program uptake."
- "Make every effort to understand the community for whom the services are being introduced. Research the target population, their families, and community structures to understand the social “ecosystem” within which they seek health services. It is important to study community perceptions of the intervention being introduced."
- "Campaigns are effective in increasing demand for services, but efforts need to be made to maintain uptake of services outside of campaigns."
- "Multimedia approaches are effective in creating rapid awareness of the service. Additionally, both longer formats and interactive programming (such as radio call-in talk shows) are effective in creating dialogue and dispelling myths about the service....It is important to create awareness about the intervention and provide avenues through which community members can interact with program representatives to discuss their concerns."
- "Demand creation activities conducted by local communities are more effective than bringing in community mobilizing agents from other areas."
- "Local leaders are effective in creating community buy-in to take up the service....Partner with CBOs; local leaders and volunteers; and local, regional, and national VMMC Champions."
AIDSTAR-One website, April 29 2014. Image credit: Natasha Kanagat, John Snow International