Behavior change pathways to male circumcision narrative interviews with VMMC clients in Zambia J....
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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
Fears
Sources 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