Study ObjectiveTo explore the theoretical basis of communication campaign designs and studies related to increasing MMC uptake in SSA priority countries.

Examples of MMC Promotion

Results

Only two articles explicitly mentioned theory, of which only one was based on operational research.

Table 1: Explicit and implicit references to theory

Introduction

Medical male circumcision (MMC) reduces men’s heterosexual HIV acquisition risk by around 60%.

The WHO & UNAIDS promote MMC as part of comprehensive HIV prevention programming, with 13 sub-Saharan African (SSA) countries identified as priorities for MMC scale-up (2007).

According to progress reports on MMC scale-up, only 2.7% of the target of 80% adult MMC coverage by 2015 has been realized (UNAIDS, 2011)

MMC’s effectiveness as a public health HIV prevention strategy depends on its adoption by affected communities at scale. The extent to which MMC promotion efforts are guided by social and behavioural theory is unknown.

Acknowledgements

The author would like to acknowledge Nicola Christofides and Leane Ramsoomar for their inputs on the poster design. Any mistakes or oversights are the authors own.

Contact Detailssara.nieuwoudt@wits.ac.za

Discussion

Despite UNAIDS guidance that MMC communication should be theory-based (2008), most articles do not mention behavioural or social theory explicitly .

The development, prioritization and evaluation of MMC promotion campaigns is generally poorly described.

Individual messages tend to focus on fact dissemination, despite poor evidence that increased MMC knowledge leads to medical circumcision uptake. There are some ethical reasons for this, e.g. discouraging risk compensation.

Many studies point to the interpersonal influences from family, peers, and partners as well as societal factors such as gender norms and religious and cultural identities as being key MMC barriers or facilitators to consider targeting in promotion.

A few articles highlight the importance of having an enabling policy environment and equipped health services before driving up community or individual MMC demand. Government and donor efforts to lower cost, increase access, and assure the safety of circumcision services are critical to successful scale up.

The articles provide evidence that could be used to build a socio-ecological model

3737 51

Recommendations

Design and evaluate explicitly theoretical MMC promotion interventions that are:

•Context-specific;

•Multi-level; and,

•Costed.

Conduct operational research comparing the cost effectiveness of different components of promotion campaign, e.g. advocacy vs. mass media vs. interpersonal outreach

Disseminate findings in open-source journals that practitioners can access.

MethodsSystematic literature review of open-source peer-

reviewed journal articles from 2007 onwards within

SSA was conducted .

Databases:

•PubMed & Google Scholar

Eligibility criteria:

•Circumcision in title

•Adult (vs. neonatal) and medical (vs. traditional) focus

•At least one sub-Saharan African country included

•Focus on MMC promotion and uptake (vs. biomedical efficacy or

post-circumcision behaviour)

Search terms (used alone and in combination):

•Male circumcision; promotion; campaigns; communication;

theory; Africa; HIV; demand creation

Study SampleSince 2007, twenty-one (21) open-source peer-

reviewed journal articles have addressed MMC

promotion in the following countries or regions:

Source: Centre for HIV/AIDS Prevention Studies (CHAPS): www.chaps.org.za

Source: Male Circumcision Clearinghouse publication library: www.malecircumcision.org/publications

Ref Articles (by year)

Article Type

Theory explicit?

MMC promotion areas highlighted or addressed within different levels of a socio-ecological framework

1 Westercamp, N. & Bailey, R.C. (2007).

Review No. Individual: (perceived) barriers and benefits; attitudes; beliefsInterpersonal: partners; parents; health providersSocietal: religious and cultural values; ethnic identity; gender norms; poverty

2 Peltzer, K. et al. (2007).

Editorial Review

Yes: “Global, socio-cultural approach”

Individual: perceptions and understandings of MCSocietal social and cultural understandings of circumcision (acceptability); gender & power in the context of MC decision-making; masculinities; social effects, e.g. discrimination; synergies between traditional and clinical settings; legal/policy contexts

3 Sawires, S.R., et al. (2007).

View Point (Editorial)

No. Individual: (perceived) benefits: partial protectionInterpersonal: couples; parentsSocietal: religious and cultural values; legal/policy context (combined prevention & health systems); gender & power; stereotyping (‘branding’males as perpetrators of infection); racial discrimination

4 Pincock, S. (2007).

World Report(Editorial)

No. Societal: legal/policy context (human resources and health systems); donor support

5 Weiss, H.A., et al. (2008).

Editorial Review

No. Individual: (perceived) benefits: partial protectionSocietal: social and cultural understandings of circumcision (acceptability); legal & ethical considerations; gender & power

6 Kagumire, R. (2008).

News (Editorial)

No. Individual: (perceived) benefits: partial protectionSocietal: political support; health systems (human resources and access); cultural values; gender norms

7 Wang, A. Duke, W. & Schmid, G. (2009).

Review No Individual: mass media as leading source of health information/knowledge for individualsSocietal: mass media as shaping/reflecting norms

8 De Bruyn, G., et al. (2009).

Pilot program evaluation

No Individual: perceived HIV risk (based on reported risk behaviours)Interpersonal: Health provider risk counseling

9 Obure, A.F.X.O., et al. (2009).

Qualitative study

Grounded theory

Individual: perceived barriers and facilitatorsSocietal: cultural identity and integration/isolation; masculities; access to services; poverty (cost)

10 Wilcken, A., et al. (2010).

Cross sectional Study

No. Individual: perceived benefitsInterpersonal: partners; parentsSocietal: religious and cultural values; access to services

11 Mwanga, J.R., et al. (2010).

Qualitative situation analysis

Grounded theory

Individual: attitudes and beliefs (policy-makers/leaders)Societal: policy/legal context

12 Lissouba, P., et al. (2010).

Operational research

No Individual: perceived benefits; knowledge; attitudesInterpersonal: partners, teachers, peers, local leaders; health providersSocietal: religious and cultural values; access; poverty (cost)

13 Wakabi, W. (2010).

World Report

No. Individual: perceived benefitsInterpersonal: partnersSocietal: cultural values; access

… Full citations of all 21 articles are available on request from the author.

21 Obure, A.F.X.O. et al. (2011).

Qualitative study

Grounded – “supports socio-ecological”

Individual: perceived benefits and barriersInterpersonal: peer, partners, teachers, leadersSocietal: religious and cultural values; gender & power

Poster References:• UNAIDS. 2008. Male circumcision and HIV prevention in Eastern and Southern Africa : communications guidance . [accessed on http://data.unaids.org/pub on 5 July, 2011] •WHO & UNAIDS. 2007. New data on male circumcision and HIV prevention: policy and programme implications. Geneva: WHO.• WHO & UNAIDS. 2011. Progress in Scale-up of Male Circumcision for HIV Prevention in Eastern and Southern Africa: Focus on service delivery – 2011. Geneva: WHO