Frade, S, Friedman, W, Rech, D and Wilson, N, 2016. Using advertisements to create demand for voluntary medical male circumcision in South Africa, 3ie Impact Evaluation Report 53. New Delhi: International Initiative for Impact Evaluation (3ie)
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This study evaluates the impact on take-up of VMMC services of five different innovative postcard-based VMMC recruitment mechanisms relative to a basic VMMC postcard.
Voluntary medical male circumcision (VMMC) reduces HIV transmission by 51-76 per cent, yet VMMC take-up remains low in South Africa. In order to have a population-level impact on HIV prevalence in South Africa, a large number of HIV-negative men would have to choose to undergo circumcision. To provide evidence on the barriers to VMMC take-up, this study assessed the impact of distributed postcards with a compensation offer, information on a possibly unknown benefit of VMMC, and/or a framing message on VMMC take-up among eligible men.
The primary aim of the study was to determine how responsive take-up of VMMC services were to five different combinations of messages, including an offer of financial compensation conditional on attending a VMMC consultation, a challenge message and information about partner preferences.
The Centre for HIV and AIDS Prevention Studies (CHAPS) in partnership with the Reed College distributed postcards to 6,000 individuals with five different combinations of messages and/or promises of compensation for transportation. Then they measured the differential impact of each postcard in encouraging phone calls and text messages to get more information, clinic visits and circumcisions. All postcards promised refreshments for those who brought these to a participating VMMC clinic. This helped make the postcards self-tracking and facilitated the estimation of the impacts of the messages on VMMC take-up.
Theory of change
The theory of change posits that financial compensation for costs associated with visiting VMMC clinics and well-designed messages that appeal to men’s interests can encourage individuals to take the steps necessary to learn about VMMC and choose to get circumcised.
In this postcard-based door-to-door marketing campaign, households were randomly assigned to receive either an offer of conditional compensation of US$10, information on a possibly previously unknown benefit of VMMC, or a framing question.
Researchers from the Reed College measured the relative strength of each treatment arm in encouraging VMMC take-up. They compared the number of text messages received and the number of clinic visits generated by each arm relative to the same numbers among those who received the ‘comparison’ postcard (which includes only basic information about HIV risk reduction common to all postcards and the promise of refreshments). Comparisons were done using a bivariate regression, with the outcome of interest as the dependent variable and an indicator for being in the ‘treated’ group as the single regressor.
Overall, 125 calls and text messages were received, 123 recipients visited clinics for consultations and 110 circumcisions were performed. A fraction of the total, approximately 2.08 per cent of postcard recipients responded with a call or text, 2.05 per cent visited a clinic, and 1.8 per cent ultimately got circumcised. Approximately, 90 per cent of those who visited a clinic for a consultation chose to get circumcised.
There is a clear impact of the offer of even a small financial compensation for transportation and take-up, which is not surprising. It does provide further evidence that this could be a technique used more broadly to encourage health behaviours that are broadly advocated.
Cost efficiency analysis
The intervention had very low costs and combined with noticeable impacts on uptake, this implies that the cost-effectiveness is relatively high. Printing and distribution of each postcard cost approximately US$2. The estimated effect on take-up of VMMC with the addition of the transport reimbursement voucher postcard relative to the basic postcard was 2.5 percentage points. This 2.5 percentage point difference in take-up implies one additional circumcision per 40 postcards. At US$2 per postcard, 40 postcard costs US$80. The cost-effectiveness of each message will depend on the cost of the method of advertising used.
Implications for policy and practice
The results in this study are relevant for any organisation or government considering various message delivery mechanisms, including radio, TV or billboard advertising. The use of the postcards with attached vouchers allows different messages to be targeted to individuals to facilitate the measurement of the impact with a relatively small sample. Simple advertising of modest conditional compensation, in which the compensation is conditioned on the VMMC consultation, may generate a noticeable increase in VMMC take-up.
Implications for further research
Future research should examine the effects of implementing these (or similar) advertising interventions at scale. Although, a message such as ‘Are you tough enough?’ generated a substantial increase in VMMC take-up, future research may be able to identify more effective advertising messages. Furthermore, future studies should also examine the effects of these interventions in other high HIV prevalence, low male circumcision contexts.