Educating religious leaders to promote uptake of male circumcision in Tanzania: a cluster randomised trial

Abstract

SummaryBackgroundMale circumcision is being widely deployed as an HIV prevention strategy in countries with high HIV incidence, but its uptake in sub-Saharan Africa has been below targets. We did a study to establish whether educating religious leaders about male circumcision would increase uptake in their village.MethodsIn this cluster randomised trial in northwest Tanzania, eligible villages were paired by proximity (<60 km) and the time that a free male circumcision outreach campaign from the Tanzanian Ministry of Health became available in their village. All villages received the standard male circumcision outreach activities provided by the Ministry of Health. Within the village pairs, villages were randomly assigned by coin toss to receive either additional education for Christian church leaders on scientific, religious, and cultural aspects of male circumcision (intervention group), or standard outreach only (control group). Church leaders or their congregations were not masked to random assignment. The educational intervention consisted of a 1-day seminar co-taught by a Tanzanian pastor and a Tanzanian clinician who worked with the Ministry of Health, and meetings with the study team every 2 weeks thereafter, for the duration of the circumcision campaign. The primary outcome was the proportion of male individuals in a village who were circumcised during the campaign, using an intention-to-treat analysis that included all men in the village. This trial is registered with ClinicalTrials.gov, number NCT 02167776.FindingsBetween June 15, 2014, and Dec 10, 2015, we provided education for church leaders in eight intervention villages and compared the outcomes with those in eight control villages. In the intervention villages, 52·8% (30 889 of 58 536) of men were circumcised compared with 29·5% (25 484 of 86 492) of men in the eight control villages (odds ratio 3·2 [95% CI, 1·4–7·3]; p=0·006).InterpretationEducation of religious leaders had a substantial effect on uptake of male circumcision, and should be considered as part of male circumcision programmes in other sub-Saharan African countries. This study was conducted in one region in Tanzania; however, we believe that our intervention is generalisable. We equipped church leaders with knowledge and tools, and ultimately each leader established the most culturally-appropriate way to promote male circumcision. Therefore, we think that the process of working through religious leaders can serve as an innovative model to promote healthy behaviour, leading to HIV prevention and other clinically relevant outcomes, in a variety of settings.FundingBill & Melinda Gates Foundation, National Institutes of Health, and the Mulago Foundation.

Use of traditional and complementary medicines by cancer patients at a national cancer referral facility in a low‐income country

“…The use of prayers and meditations for ill health is very common, especially among patients with cancer (Chui, Abdullah, Wong, & Taib, ; Farooqui et al, ). This finding potentially informs interventions for management of cancers based on involvement of religious leaders who have, in fact, been found very effective in promoting health awareness and increasing uptake of services, including male circumcision (Downs et al, ).…”

The effectiveness of demand creation interventions for voluntary male medical circumcision for HIV prevention in sub‐Saharan Africa: a mixed methods systematic review

“…In the eight intervention villages 1194 leaders received training. The proportion of the male population who had presented for VMMC by the end of the study was 23.3% (22.8 to 23.8) higher in intervention villages compared to the paired control villages (52.8% compared to 29.5%; OR 3.2 (1.4‐7.3)) The authors estimated that this led to an additional 13,000 circumcisions being performed in the intervention villages .…”

“…Second, more personal interventions delivered by people with relevant experience can resonate well, as with the football interventions . Third, addressing broader social and cultural influences through partnership with and education of community leaders can have a wide impact .…”

“…Downs et al . conducted a CRCT which trained church leaders to educate and promote VMMC to their congregations (one‐day course) . Eight pairs of villages were randomized with an estimated population of 145,028 exposed to Church leaders’ teachings.…”

“…Theories have suggested that role models, families and peers play a part in changing an individual's behaviour . This review found that religious leaders could play a key role in disseminating information and appear to address the challenge of norms and social acceptability . Carrasco et al .…”