DeCelles, J, Kaufman, Z, Bhauti, K, Hershow, R, Weiss, H, Chaibva, C, Moyo, N, Braunschweig, E, Mantula, F, Hatzold, K and Ross, D, 2016. Voluntary medical male circumcision uptake through soccer in Zimbabwe, 3ie Impact Evaluation Report 50. New Delhi: International Initiative for Impact Evaluation (3ie)
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The study evaluates the effectiveness of the Make the Cut (MTC+) intervention with adolescent males which involved a 60-minute, interactive, soccer-themed learning intervention experience promoting male circumcision led by a trained circumcision coach.
In Zimbabwe, the voluntary medical male circumcision (VMMC) strategy was initiated in 2009 by the Ministry of Health and Child Welfare (MOHCW), which outlined aims to reach 80 per cent of 13-29 year-old males in Zimbabwe between 2011 and 2015. Despite progress in supply scale-up, Zimbabwe is falling well short of its target of 80 per cent VMMC coverage by 2015. This reflects the urgent need to identify and scale-up effective interventions that increase VMMC demand. The study examines whether the MTC+ intervention can substantially and significantly increase demand for VMMC in secondary schools.
The main research question of the evaluation was to determine the extent to which the MTC+ intervention was effective in increasing demand for VMMC among adolescent males attending secondary school in Bulawayo.
The MTC+ intervention consisted of a 60-minute session delivered in schools by a trained facilitator or coach – a circumcised man aged 18- 30 years recruited and trained by the NGO, Grassroot Soccer (GRS) to deliver the intervention. MTC+ intervention consisted of the following: (1) a 60-minute soccer-themed educational session led by a trained, circumcised coach; (2) Information, education and communication materials on male circumcision; (3) referrals and phone-based follow-up to interested participants conducted by coaches; and (4) soccer-based incentives to all participants who complete VMMC.
Theory of change
The theory of change posits that young men in Zimbabwe need additional knowledge and motivation to undergo VMMC. Building on promising uptake findings from the Male Circumcision Uptake Through Soccer (MCUTS) trial and qualitative findings suggesting higher acceptability of MTC among younger men, the MTC+ intervention will be delivered by trained, circumcised MTC+ coaches – a mix of professional soccer players and community role models – to 15-19 year-old male students in public secondary schools in Bulawayo.
A cluster-randomised trial was carried out to assess the effectiveness of MTC+. VMMC uptake at the two Bulawayo VMMC clinics over the four-month study period (beginning of March to beginning of July) were compared between the two study groups.
Baseline and four-month follow-up surveys were self-administered (in school classrooms) using mobile phones provided by the trial. The questionnaires were programmed using Open Data Kit, an open access software tool. Focus group discussions and in-depth interviews with coaches and participants addressed how and why the intervention was or was not effective in increasing demand for VMMC. The interventions were carefully costed and a cost-effectiveness analysis was carried out to determine the cost generated per new VMMC patient.
The study revealed strong evidence that the MTC+ intervention increased VMMC uptake among adolescent males in Bulawayo schools over 2.5 fold over a period of four months or by approximately 7.6 percentage points. The observed effect was consistent, whether considering all participants or restricting the analysis to participants not reporting being already circumcised at baseline. It was evident across three levels of sensitivity analysis, with the strictest level of analysis suggesting that relative effect may actually be closer to three-fold.
Cost efficiency analysis
The implementation cost of the MTC+ intervention with 565 intervention participants (regardless of VMMC status) is US$1.99 per participant. Of these, 41 participants went for VMMC, resulting in a cost of US$27.36 per client in the intervention group. Taking into account the observed absolute effect of the intervention (the difference in VMMC uptake between groups), the approximate cost per additional VMMC client was $45.31 among all participants or $48.61 among participants not reporting being circumcised at baseline.
Implications for policy and practice
This study provides strong evidence of MTC+ effectiveness in Bulawayo schools. If the intervention’s effectiveness remains consistent at scale, the MTC+ intervention could generate valuable new VMMC demand among adolescent males, if scaled up in schools.
Implications for further research
Further research should focus on the impact of MTC+ in different settings, such as rural schools and with slightly different age groups. Furthermore, MTC+ was directly implemented by experienced HIV education facilitators under close supervision by GRS. Researchers should investigate VMMC uptake among participants that receive MTC+ via implementing partners.