Behavior change pathways to male circumcisionnarrative interviews with VMMC clients in Zambia

J. Price1, D. Mulenga1, L. Phiri1, P. Hewett1, K. Hatzold2, N. Shiliya3, K. Bowa4

July 1, 2013

1Population Council/Zambia, 2Population Services International/Zimbabwe, 3Society for Family Health/Zambia, 4Copperbelt University/Zambia

Objectives and Methods

ObjectiveUnderstand the behavior change process leading to MC-seeking

Methods and theorized behavior change stagesNarrative interviews with 40 clients (≥18 years old) waiting for surgical MC at two Lusaka clinics

ContextZambia has experienced challenges in meeting VMMC targets in adult men

CommitmentEarly actionContemplationInitial exposure and impressions

Stage 1 Stage 2 Stage 3 Stage 4

Empirically-Determined Behavior Change Stages

Exposure and belief

adjustment

Personalizing benefits and

norming pressures

Conquering fears and

taking charge of Self

Taking action, seeking MC

Stage 1 Stage 2 Stage 3 Stage 4

Most Frequently Cited Sources of Information, Advantages, and

FearsSources of

Information

Perceived Advantages

Major Fears

(n=40)

Pain

Healing

Hygeine

HIV/STI prevention

Mass media

Personal network

0% 20% 40% 60% 80% 100%

Cited Not cited

I met a girl named Alice . . .Stage 1: Exposure & Belief

AdjustmentI met a girl named Alice.

She’s the one who enticed me to do it. She came with a

brochure and said, ‘you know honey, there’s something we

can do to make our love more enjoyable.’

I started to see it wasn’t dangerous because even my best friend from the Copperbelt did it. He even showed me. I then talked to my

wife and she said “you can do it.”

MC is . . .• safe• for Christians too• for all ethnic groups• for adult men

Main Beliefs Adjusted

This is an honest opinion, everyone around me has gone [for MC], so I feel different. Now I just feel like I’m doing what a

man is supposed to do. I was being left behind because everyone else has done it.

I feel different . . .Stage 2: Personalization & Norming

Pressures

If I don’t get circumcised I’ll be . . .• left behind• missing out• left out of the group• different

If I do get circumcised I’ll be . . .• responsible• sexually appealing• clean• safe• like other men

I told myself . . . • just forget your fears • no pain lasts forever• all wounds eventually heal• other men have done it• it’s my . . .

life health future

I’m ready now . . .Stage 3: Conquering Fears, Taking Charge

I’m ready now, I even feel desperate. It’s like having a thirst. I need to drink water.

I wanted to go to X clinic but found it was a celebration of cancer day today. I went home and sat down in my chair. Then I thought to myself, since I decided that I should do

this today, why don't I try Y?

I woke up, had my breakfast, brushed my teeth, and came here . . .

Stage 4: Commitment, MC Seeking

• First 24 (60%) • Second 12 (30%)• Third 4 (10%)

Number of attempts to obtain MC

Service-Side Access Barriers Encountered

• MC not offered that day 6 • Lack of privacy, information 4• Wait too long, too many people 2• Came too late, turned away 2• Too many people, turned away 1• Female provider 1• MC services canceled 1• Clinic closed (Sunday) 1• Second thoughts, doubted clinic 1• Unclear from the interview 1

• First 24 (60%) • Second 12 (30%)• Third 4 (10%)

= 20 failed MC attempts in total

Number of attempts to obtain MC

Implications and Recommendations

Exposure and belief

adjustment

Personalizing benefits and

norming pressures

Conquering fears and

taking charge of Self

Taking action, seeking MC

Stage 1 Stage 2 Stage 3 Stage 4

1. Continue multi-media communications

2. But diversify messaging• Target network

members• Emphasize secondary

benefits• Emphasize that MC is

for EveryMAN

1. Use MC-experienced men (I did it, so can you)

2. Offer more places where men can get their specific questions answered

1. Advertise clinic hours, days

2. Introduce by-appointment-only scheduling

3. Improve processing efficiencies at the clinic