Behavior Change Pathways to Voluntary Medical Male Circumcision: Narrative Interviews with Circumcision Clients in Zambia

Abstract

As an HIV prevention strategy, the scale-up of voluntary medical male circumcision (VMMC) is underway in 14 countries in Africa. For prevention impact, these countries must perform millions of circumcisions in adolescent and adult men before 2015. Although acceptability of VMMC in the region is well documented and service delivery efforts have proven successful, countries remain behind in meeting circumcision targets. A better understanding of men's VMMC-seeking behaviors and experiences is needed to improve communication and interventions to accelerate uptake. To this end, we conducted semi-structured interviews with 40 clients waiting for surgical circumcision at clinics in Zambia. Based on Stages of Change behavioral theory, men were asked to recount how they learned about adult circumcision, why they decided it was right for them, what they feared most, how they overcame their fears, and the steps they took to make it to the clinic that day. Thematic analysis across all cases allowed us to identify key behavior change triggers while within-case analysis elucidated variants of one predominant behavior change pattern. Major stages included: awareness and critical belief adjustment, norming pressures and personalization of advantages, a period of fear management and finally VMMC-seeking. Qualitative comparative analysis of ever-married and never-married men revealed important similarities and differences between the two groups. Unprompted, 17 of the men described one to four failed prior attempts to become circumcised. Experienced more frequently by older men, failed VMMC attempts were often due to service-side barriers. Findings highlight intervention opportunities to increase VMMC uptake. Reaching uncircumcised men via close male friends and female sex partners and tailoring messages to stage-specific concerns and needs would help accelerate men's movement through the behavior change process. Expanding service access is also needed to meet current demand. Improving clinic efficiencies and introducing time-saving procedures and advance scheduling options should be considered.

Increasing voluntary medical male circumcision uptake among adult men in Tanzania

“…The booths were managed by peer promoters and health facility staff and addressed the women's questions on VMMC and were also used to coach women on how to encourage male partners who were undecided or reluctant to seek circumcision. Several studies have shown that women influence their partners’ decision to be circumcised [23,32,33]. Providing correct information to women empowers them to play this role and may be an effective way of reaching married adult men.…”

Unpacking early infant male circumcision decision-making using qualitative findings from Zimbabwe

“…Despite adult VMMC scale-up in the 14 priority countries over the last 4–5 years, researchers have not yet managed to adequately dissect the adult VMMC decision-making process. Some research groups have attempted to do this and have identified some of the important factors while acknowledging that their understanding of the process is incomplete [34–36]. They have, however, identified a range of motivators, including those unrelated to risk of HIV including improved hygiene, perceptions of responsible masculine choice, perceptions of sexual partner preferences, and improved health for female sexual partners (e.g.…”

“…They have, however, identified a range of motivators, including those unrelated to risk of HIV including improved hygiene, perceptions of responsible masculine choice, perceptions of sexual partner preferences, and improved health for female sexual partners (e.g. reduced risk of cervical cancer) [34, 36]. …”

Disclosing Parental HIV Status to Children in China: Lessons Learned Through an Intervention Study

“…Sessions were also audio-recorded with participant consent. We explored the nurse interventionist notes using content analysis (Denis, 2014; Price et al, 2014), which focused on the experiences of a small number of participants rather than those of a larger group, with the goal of giving voice to those whose stories had not been heard in published literature. Specifically, we explored themes related to the sharing of sensitive personal information within families in China, a setting of low mental-health resources and high HIV-related stigma (Li et al, 2009).…”